Perceived needs for the information communication technology (ICT)-based personalized health management program, and its association with information provision, health-related quality of life (HRQOL), and decisional conflict in cancer patients

OBJECTIVE

The use of information communication technology (ICT)-based tailored health management program can have significant health impacts for cancer patients. Information provision, health-related quality of life (HRQOL), and decision conflicts were analyzed for their relationship with need for an ICT-based personalized health management program in Korean cancer survivors.

METHODS

The health program needs of 625 cancer survivors from two Korean hospitals were analyzed in this cross-sectional study. Multivariate logistic regression was used to identify factors related to the need for an ICT-based tailored health management system. Association of the highest such need with medical information experience, HRQOL, and decision conflicts was determined. Furthermore, patient intentions and expectations for a web- or smartphone-based tailored health management program were investigated.

RESULTS

Cancer survivors indicated high personalized health management program needs. Patients reporting the highest need included those with higher income (adjusted odds ratio [aOR], 1.70; 95% [confidence interval] CI, 1.10-2.63), those who had received enough information regarding helping themselves (aOR, 1.71; 95% CI, 1.09-2.66), and those who wished to receive more information (aOR, 1.59; 95% CI, 0.97-2.61). Participants with cognitive functioning problems (aOR, 2.87; 95%CI, 1.34-6.17) or appetite loss (aOR, 1.77; 95% CI, 1.07-2.93) indicated need for a tailored health care program. Patients who perceived greater support from the decision-making process also showed the highest need for an ICT-based program (aOR, 0.49; 95% CI, 0.30-0.82).

CONCLUSIONS

We found that higher income, information provision experience, problematic HRQOL, and decisional conflicts are significantly associated with the need for an ICT-based tailored self-management program.

Anthropometric Study of the Stomach

Purpose

The aim of this study was to establish an anthropometric reference of the stomach for gastric cancer surgery and a modeling formula to predict stomach length.

Materials and Methods

Data were retrieved for 851 patients who underwent total gastrectomy at the Seoul National University Hospital between 2008 and 2013. Clinicopathological data and measurements from a formalin-fixed specimen were reviewed. The lengths (cm) of the greater curvature (GC) and lesser curvature (LC) were measured. Anthropometric data of the stomach were compared according to age, body weight, height (cm), and body mass index. To predict stomach length, two multiple regression analyses were performed.

Results

The mean lengths of the GC and LC were 22.2±3.1 cm and 16.3±2.6 cm, respectively. The men’s GC length was significantly greater than the women’s (22.4±3.1 cm vs. 21.2±2.9 cm, P=0.003). Patients aged >70 years showed significantly longer LC than those aged <50 years (16.9±2.9 cm vs. 15.9±2.4 cm, P=0.002). Patients with body weights >70 kg showed significantly longer GC than those with body weights <55 kg (23.0±2.9 cm vs. 21.4±3.2cm, P<0.001). In the predicted models, 4.11% of the GC was accounted for by age and weight; and 4.94% of the LC, by age, sex, height, and weight.

Conclusions

Sex, age, height, and body weight were associated with the length of the LC, while sex and body weight were the only factors that were associated with the length of the GC. However, the prediction model was not sufficiently strong.

Postoperative Quality of Life after Total Gastrectomy Compared with Partial Gastrectomy: Longitudinal Evaluation by European Organization for Research and Treatment of Cancer-OG25 and STO22

PURPOSE

The European Organization for Research and Treatment of Cancer quality-of-life questionnaire-OG25 was developed to evaluate the quality of life in patients with stomach and esophageal cancer. The following are included in the OG25 but not in the STO22: odynophagia, choked when swallowing, weight loss, trouble eating with others, trouble swallowing saliva, trouble talking, and trouble with coughing. In this study, we evaluated the quality of life of gastrectomized patients using both, the OG25 and the STO22.

MATERIALS AND METHODS

A total of 138 patients with partial gastrectomy (PG) (distal gastrectomy=91; pylorus-preserving gastrectomy= 47) and 44 patients with total gastrectomy (TG) were prospectively evaluated. Body weight and scores from the OG25 and STO22 were evaluated preoperatively and at 3 weeks, 3 months, and 6 months after surgery.

RESULTS

Patients with TG had significant weight loss compared to patients with PG. At 3 months, TG was associated with worse scores for dysphagia, eating, odynophagia, trouble eating with others, trouble with taste, and weight loss on the OG25. TG was also associated with dysphagia, eating restrictions, and anxiety on the STO22. The OG25 helped differentiate between the groups with respect to weight loss, odynophagia, choked when swallowing, and trouble eating with others. The OG25 scores changed over time and were significantly different.

CONCLUSIONS

The OG25 is a more sensitive and useful scale than the STO22 for evaluating the quality of life of gastrectomized patients, especially those with total gastrectomy.

Effect of Previous Gastrectomy on the Performance of Postoperative Colonoscopy

Purpose

The purpose of this study was to determine the effect of a prior gastrectomy on the difficulty of subsequent colonoscopy, and to identify the surgical factors related to difficult colonoscopies.

Materials and Methods

Patients with a prior gastrectomy who had undergone a colonoscopy between 2011 and 2014 (n=482) were matched (1:6) to patients with no history of gastrectomy (n=2,892). Cecal insertion time, intubation failure, and bowel clearance score were compared between the gastrectomy and control groups, as was a newly generated comprehensive parameter for a difficult/incomplete colonoscopy (cecal intubation failure, cecal insertion time >12.9 minutes, or very poor bowel preparation scale). Surgical factors including surgical approach, extent of gastrectomy, extent of lymph node dissection, and reconstruction type, were analyzed to identify risk factors for colonoscopy performance.

Results

A history of gastrectomy was associated with prolonged cecal insertion time (8.7±6.4 vs. 9.7±6.5 minutes; P=0.002), an increased intubation failure rate (0.1% vs. 1.9%; P<0.001), and a poor bowel preparation rate (24.7 vs. 29.0; P=0.047). Age and total gastrectomy (vs. partial gastrectomy) were found to be independent risk factors for increased insertion time, which slowly increased throughout the postoperative duration (0.35 min/yr). Total gastrectomy was the only independent risk factor for the comprehensive parameter of difficult/incomplete colonoscopy.

Conclusions

History of gastrectomy is related to difficult/incomplete colonoscopy performance, especially in cases of total gastrectomy. In any case, it may be that a pre-operative colonoscopy is desirable in selected patients scheduled for gastrectomy; however, it should be performed by an expert endoscopist each time.

The Korean Gastric Cancer Cohort Study: Study Protocol and Brief Results of a Large-Scale Prospective Cohort Study

Purpose

This study aimed to establish a large-scale database of patients with gastric cancer to facilitate the development of a national-cancer management system and a comprehensive cancer control policy.

Materials and Methods

An observational prospective cohort study on gastric cancer was initiated in 2010. A total of 14 cancer centers throughout the country and 152 researchers were involved in this study. Patient enrollment began in January 2011, and data regarding clinicopathological characteristics, life style-related factors, quality of life, as well as diet diaries were collected.

Results

In total, 4,963 patients were enrolled until December 2014, and approximately 5% of all Korean patients with gastric cancer annually were included. The mean age was 58.2±11.5 years, and 68.2% were men. The number of patients in each stage was as follows: 3,394 patients (68.4%) were in stage IA/B; 514 patients (10.4%), in stage IIA/B; 469 patients (9.5%), in stage IIIA/B/C; and 127 patients (2.6%), in stage IV. Surgical treatment was performed in 3,958 patients (79.8%), endoscopic resection was performed in 700 patients (14.1%), and 167 patients (3.4%) received palliative chemotherapy. The response rate for the questionnaire on the quality of life was 95%; however, diet diaries were only collected for 27% of patients.

Conclusions

To provide comprehensive information on gastric cancer for patients, physicians, and government officials, a large-scale database of Korean patients with gastric cancer was established. Based on the findings of this cohort study, an effective cancer management system and national cancer control policy could be developed.

Ultrasonically Activated Shears Reduce Blood Loss without Increasing Inflammatory Reactions in Open Distal Gastrectomy for Cancer: A Randomized Controlled Study

BACKGROUND

Previous studies regarding ultrasonically activated shears (UAS) were performed without controlled surgical procedures or consideration of potential thermal injury due to high temperature of active blade of UAS. The purpose of this study was to evaluate the efficacy and safety of UAS through a comparison with conventional monopolar electrocautery (CME) in open distal gastrectomy for gastric cancer.

METHODS

From October 2011 to November 2012, 56 gastric cancer patients eligible for open distal gastrectomy were randomized into UAS or CME groups. Primary endpoints were estimated blood loss (EBL) during surgery and amount of drainage through the fifth postoperative day. Secondary endpoints were operation time, length of hospital stay, postoperative morbidity, changes in cytokine levels in serum, peritoneal irrigation saline, and peritoneal drainage, and inflammatory markers of serum. (Registration-number of ClinicalTrials.gov: NCT01971775).

RESULTS

EBL was lower in the UAS group than that in the CME group (339.8 ± 201.2 vs. 428.6 ± 165.8 mL, p = 0.021). However, the amount of postoperative drainage was not significantly different between the two groups. Although the complication rate was not different between the two groups, there were three cases of intra-abdominal bleeding requiring transfusion only in the CME group. Inflammatory markers from the cytokine assays and serum laboratory tests showed no significant differences between the two groups.

CONCLUSIONS

UAS reduced EBL without increasing inflammatory reactions.

Short- and Long-Term Outcomes After Gastrectomy in Elderly Gastric Cancer Patients

BACKGROUND

The number of elderly patients undergoing gastric cancer surgery has recently increased. We therefore evaluated the short- and long-term outcomes of elderly patients after curative gastrectomy.

METHODS

Overall, 824 patients were included in this retrospective study, which comprised of a non-elderly group (60-64 years; n = 558), an early-elderly group (75-79 years; n = 198), and a late-elderly group (≥80 years; n = 68) who underwent curative gastrectomy for gastric cancer between 2005 and 2009. Postoperative complications, according to the Clavien-Dindo classification, and survival of both elderly groups were compared with the non-elderly group. Postoperative life expectancy of the late-elderly group was compared with the corresponding aged general population.

RESULTS

Overall and severe (grade III or higher) complications in the early-elderly group were comparable with the non-elderly group; however, those in the late-elderly group were significantly more common than in the non-elderly group (p = 0.013 and p = 0.043, respectively). Multivariable analysis revealed that age ≥80 years was an independent risk factor for severe complications (hazard ratio 3.02, 95 % confidence interval 1.12-8.17; p = 0.029), and the disease-specific survivals of both elderly groups were comparable with the non-elderly group in all TNM stages. Postoperative life expectancy of late-elderly patients eliminating death from recurrence was comparable with the corresponding aged general population eliminating death from gastric cancer.

CONCLUSIONS

Gastric cancer surgery in elderly patients aged ≥80 years achieves reasonable long-term survival despite the increased risk of severe complications.

Who may benefit from robotic gastrectomy?: A subgroup analysis of multicenter prospective comparative study data on robotic versus laparoscopic gastrectomy

AIMS

Robotic gastrectomy for gastric cancer has been proven to be a feasible and safe minimally invasive procedure. However, our previous multicenter prospective study indicated that robotic gastrectomy is not superior to laparoscopic gastrectomy. This study aimed to identify which subgroups of patients would benefit from robotic gastrectomy rather than from conventional laparoscopic gastrectomy.

METHODS

A prospective multicenter comparative study comparing laparoscopic and robotic gastrectomy was previously conducted. We divided the patients into subgroups according to obesity, type of gastrectomy performed, and extent of lymph node dissection. Surgical outcomes were compared between the robotic and laparoscopic groups in each subgroup.

RESULTS

A total of 434 patients were enrolled into the robotic (n = 223) and laparoscopic (n = 211) surgery groups. According to obesity and gastrectomy type, there was no difference in the estimated blood loss (EBL), number of retrieved lymph nodes, complication rate, open conversion rate, and the length of hospital stay between the robotic and laparoscopic groups. According to the extent of lymph node dissection, the robotic group showed a significantly lower EBL than did the laparoscopic group after D2 dissection (P = 0.021), while there was no difference in EBL in patients that did not undergo D2 dissection (P = 0.365).

CONCLUSION

Patients with gastric cancer undergoing D2 lymph node dissection can benefit from less blood loss when a robotic surgery system is used.

Asian Consensus Guidelines for the Diagnosis and Management of Gastrointestinal Stromal Tumor

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors originating in the gastrointestinal tract. With the introduction of molecular-targeted therapy for GISTs which has yielded remarkable outcomes, these tumors have become a model of multidisciplinary oncological treatment. Although Western clinical guidelines are available for GISTs, such as those published by the National Comprehensive Cancer Network (NCCN) and the European Society of Medical Oncology (ESMO), the clinical situations in Asian countries are different from those in Western countries in terms of diagnostic methods, surgical approach, and availability of new targeted agents. Accordingly, we have reviewed current versions of several GIST guidelines published by Asian countries (Japan, Korea, China, and Taiwan) and the NCCN and ESMO and discussed the areas of dissensus. We here present the first version of the Asian GIST consensus guidelines that were prepared through a series of meetings involving multidisciplinary experts in the four countries. These guidelines provide an optimal approach to the diagnosis and management of GIST patients in Asian countries.

Pylorus-Preserving Gastrectomy for Gastric Cancer

Pylorus-preserving gastrectomy (PPG) is a function-preserving surgery for the treatment of early gastric cancer (EGC), aiming to decrease the complication rate and improve postoperative quality of life. According to the Japanese gastric cancer treatment guidelines, PPG can be performed for cT1N0M0 gastric cancer located in the middle-third of the stomach, at least 4.0 cm away from the pylorus. Although the length of the antral cuff gradually increased, from 1.5 cm during the initial use of the procedure to 3.0 cm currently, its optimal length still remains unclear. Standard procedures for the preservation of pyloric function, infra-pyloric vessels, and hepatic branch of the vagus nerve, make PPG technically more difficult and raise concerns about incomplete lymph node dissection. The short- and long-term oncological and survival outcomes of PPG were comparable to those for distal gastrectomy, but with several advantages such as a lower incidence of dumping syndrome, bile reflux, and gallstone formation, and improved nutritional status. Gastric stasis, a typical complication of PPG, can be effectively treated by balloon dilatation and stent insertion. Robot-assisted pylorus-preserving gastrectomy is feasible for EGC in the middle-third of the stomach in terms of the short-term clinical outcome. However, any benefits over laparoscopy-assisted PPG (LAPPG) from the patient's perspective have not yet been proven. An ongoing Korean multicenter randomized controlled trial (KLASS-04), which compares LAPPG and laparoscopy-assisted distal gastrectomy for EGC in the middle-third of the stomach, may provide more clear evidence about the advantages and oncologic safety of PPG.

Gastric Carcinogenesis in the miR-222/221 Transgenic Mouse Model

Purpose

MicroRNAs (miRNAs) regulate various cellular functions, including development, cell proliferation, apoptosis, and tumorigenesis. Different signatures associated with various tissue types, diagnosis, progression, prognosis, staging, and treatment response have been identified by miRNA expression profiling of human tumors. miRNAs function as oncogenes or as tumor suppressors. The relationship between gastric cancer and miRNA garnered attention due to the high incidence of gastric cancer in Asian countries. miR-222/221 expression increases in gastric tumor tissues. The oncogenic effect of miR-222/221 was previously determined in functional studies and xenograft models. In this study, transgenic mice over-expressing miR-222/221 were generated to confirm the effect of miR-222/221 on gastric carcinogenesis.

Materials and Methods

At 6 weeks of age, 65 transgenic mice and 53 wild-type mice were given drinking water containing N-nitroso-N-methylurea (MNU) for 5 alternating weeks to induce gastric cancer. The mice were euthanized at 36 weeks of age and histologic analysis was performed.

Results

Hyperplasia was observed in 3.77% of the wild-type mice and in 18.46% of the transgenic mice (p=0.020). Adenoma was observed in 20.75% of the wild-type mice and 26.15% of the transgenic mice (p=0.522). Carcinoma was observed in 32.08% of the wild-type mice and 41.54% of the transgenic mice (p=0.341). The frequency of hyperplasia, adenoma, and carcinoma was higher in transgenic mice, but the difference was statistically significant only in hyperplasia.

Conclusion

These results suggest that hyperplasia, a gastric pre-cancerous lesion, is associated with miR-222/221 expression but miR-222/221 expression does not affect tumorigenesis itself.

miR-30-HNF4γ and miR-194-NR2F2 regulatory networks contribute to the upregulation of metaplasia markers in the stomach

OBJECTIVE

Intestinal metaplasia and spasmolytic polypeptide-expressing metaplasia (SPEM) are considered neoplastic precursors of gastric adenocarcinoma and are both marked by gene expression alterations in comparison to normal stomach. Since miRNAs are important regulators of gene expression, we sought to investigate the role of miRNAs on the development of stomach metaplasias.

DESIGN

We performed miRNA profiling using a quantitative reverse transcription-PCR approach on laser capture microdissected human intestinal metaplasia and SPEM. Data integration of the miRNA profile with a previous mRNA profile from the same samples was performed to detect potential miRNA-mRNA regulatory circuits. Transfection of gastric cancer cell lines with selected miRNA mimics and inhibitors was used to evaluate their effects on the expression of putative targets and additional metaplasia markers.

RESULTS

We identified several genes as potential targets of miRNAs altered during metaplasia progression. We showed evidence that HNF4γ (upregulated in intestinal metaplasia) is targeted by miR-30 and that miR-194 targets a known co-regulator of HNF4 activity, NR2F2 (downregulated in intestinal metaplasia). Intestinal metaplasia markers such as VIL1, TFF2 and TFF3 were downregulated after overexpression of miR-30a in a HNF4γ-dependent manner. In addition, overexpression of HNF4γ was sufficient to induce the expression of VIL1 and this effect was potentiated by downregulation of NR2F2.

CONCLUSIONS

The interplay of the two transcription factors HNF4γ and NR2F2 and their coordinate regulation by miR-30 and miR-194, respectively, represent a miRNA to transcription factor network responsible for the expression of intestinal transcripts in stomach cell lineages during the development of intestinal metaplasia.

One-Year Experience Managing a Cancer Survivorship Clinic Using a Shared-Care Model for Gastric Cancer Survivors in Korea

Given the rapid growth of the population of cancer survivors, increased attention has been paid to their health problems. Although gastric cancer is one of the most common cancers, empirical evidence of survivorship care is limited. The objectives of this study were to describe the health care status of gastric cancer survivors and to report the experience of using the shared-care model during a one-year experience at the cancer survivorship clinic in Seoul National University Hospital. This is a descriptive, single-center study of 250 long-term gastric cancer survivors who were referred to the survivorship clinic. The status of their health behaviors, comorbid conditions, secondary cancer screenings, and survivorship care status were investigated through questionnaires and examining the medical records. Among the survivors, 7.2% were current smokers, 8.8% were at-risk drinkers, and 32.4% were physically inactive. Among the patients who did not know their bone density status, the majority were in the osteopenic (37.1%) or osteoporotic range (24.1%). Screening among the eligible population within the recommended time intervals were 76.3% for colorectal cancer, but only 13.6% for lung cancer. All of the survivors were provided with counseling and medical management at the survivorship clinic, as appropriate. In conclusion, Long-term gastric cancer survivors have various unmet needs. Shared-care through survivorship clinics can be an effective solution for providing comprehensive care to cancer survivors.

Single incision gastrectomy for gastric cancer

Based on rapid development of laparoscopic techniques and instruments, single-incision laparoscopic surgery (SILS) is expected to be the next step of "more" minimally invasive surgery. A few institutions gradually started to report their experience of single incision gastrectomy (SIG) for gastric cancer, but it is still difficult to accept that SIG can be performed as a popular procedure because of its technical difficulty. For wide adoption of SIG, the simplicity, safety and reproducibility of not only lymph node dissection but also reconstruction should be evaluated compared to a conventional procedure. With a thorough understanding of unique characteristics of SILS, single incision distal gastrectomy (SIDG) for early gastric cancer performed by laparoscopic surgeons with advanced technique is expected to have promising potential about excellent cosmesis, comparable morbidity and mortality in carefully selected patients. For appropriate adoption and steady progress of this state-of-the art surgery, scientific evaluation with healthy critics is necessary with new generation of SILS instrument platform.

Serum preadipocyte factor 1 concentrations and risk of developing diabetes: a nested case-control study

AIM

To determine whether preadipocyte factor 1 could be a predictive marker for the development of diabetes in people without diabetes at baseline.

METHODS

We conducted a population-based, nested case-control study of individuals who progressed to diabetes (n = 43) or prediabetes (n = 345) and control participants matched on age, sex and fasting plasma glucose concentration, who maintained normal glucose tolerance (n = 389) during a 4-year follow-up using data from the Chungju Metabolic disease Cohort Study. Circulating levels of preadipocyte factor 1 were measured using an enzyme-linked immunosorbent assay.

RESULTS

Baseline serum preadipocyte factor 1 levels showed a stepwise decrease across the glucose tolerance status groups at follow-up (normal glucose tolerance: 10.02 ± 3.02 ng/ml; prediabetes: 9.48 ± 3.35 ng/ml; diabetes: 8.66 ± 3.29 ng/ml; P for trend, 0.0151). Individuals whose fasting plasma glucose level had increased or whose homeostasis model assessment of β-cell function had decreased at follow-up showed significantly lower levels of preadipocyte factor 1 compared with their control group counterparts. After adjusting for age, BMI, fasting plasma glucose, serum insulin levels, systolic blood pressure and triglycerides, the incidence of diabetes was nearly threefold higher in the lowest vs. the upper three quartiles of circulating preadipocyte factor 1 (relative risk 2.794; 95% CI 1.188-6.571; P = 0.0185). Notably, these findings were significant in women but not in men.

CONCLUSIONS

Levels of circulating preadipocyte factor 1 may be a useful biomarker for identifying women at high risk of developing diabetes.

A multinational phase II clinical trial of neoadjuvant imatinib for large gastrointestinal stromal tumor of the stomach

130

Background: Neoadjuvant therapy is expected to reduce the risk of primary surgery, such as rupture of the tumor, hemorrhage, and multi-visceral resection, and to improve survivals for patients with a large gastric gastrointestinal stromal tumor (GIST). This study aims to evaluate the efficacy and safety of neoadjuvant imatinib therapy for a large gastric GIST. Methods: Patients with gastric GIST, which is 10cm or larger and without metastasis, received neoadjuvant imatinib (400mg/day) for 6 months, and up to 9 months if maximal response is expected. Postoperative adjuvant imatinib was prescribed for at least 1 year and up to 3 years according to adjuvant treatment guideline. The primary endpoint was complete (R0) resection rate. A primary analysis were performed by the time all the operations were finished, to examine the efficacy and safety of the neoadjuvant treatment. Results: Between Feb 2010 and Sep 2014, 55 patients were enrolled in Japan and Korea. One patient with a jejunal GIST and one patient with PDGFRA-18 D842V mutation were excluded from analysis. Mean tumor diameter was 12cm (10-23). 86.8% of patients (46/53) completed neoadjuvant treatment. Dose reduction of imatinib was performed in 26.4% (14/53). The most frequent Grade 3 or 4 adverse events were G3 rash (5/53, 9.4%) and G3/4 neutropenia (4/53, 7.5%). Disease control rate (PR+SD) and response rate (PR) of neoadjuvant imatinib was 100% and 62.3% by RECIST, and 100% and 98.1% by Choi criteria, respectively. There was no case of CR or PD. 50 patients underwent operation, and R0 resection rate was 90.6% (n = 48, 95% CI 79.3% - 96.9%), which was significantly higher than the threshold value of 70% (p < 0.001). Combined resection of other organs (except gall bladder) was performed in 24.5% (n = 13), and 83.0% of patients (n = 44) could preserve ≥ 50% of the stomach. Postoperative complication occurred in 18.0% (9/50). Conclusions: Neoadjuvant imatinib treatment is effective and safe treatment option for a large primary GIST allowing high R0 resection rate with acceptable incidence of adverse events and postoperative complications. Clinical trial information: UMIN000003114.

Gastrectomy plus chemotherapy versus chemotherapy alone for advanced gastric cancer with a single non-curable factor (REGATTA): a phase 3, randomised controlled trial

BACKGROUND

Chemotherapy is the standard of care for incurable advanced gastric cancer. Whether the addition of gastrectomy to chemotherapy improves survival for patients with advanced gastric cancer with a single non-curable factor remains controversial. We aimed to investigate the superiority of gastrectomy followed by chemotherapy versus chemotherapy alone with respect to overall survival in these patients.

METHODS

We did an open-label, randomised, phase 3 trial at 44 centres or hospitals in Japan, South Korea, and Singapore. Patients aged 20-75 years with advanced gastric cancer with a single non-curable factor confined to either the liver (H1), peritoneum (P1), or para-aortic lymph nodes (16a1/b2) were randomly assigned (1:1) in each country to chemotherapy alone or gastrectomy followed by chemotherapy by a minimisation method with biased-coin assignment to balance the groups according to institution, clinical nodal status, and non-curable factor. Patients, treating physicians, and individuals who assessed outcomes and analysed data were not masked to treatment assignment. Chemotherapy consisted of oral S-1 80 mg/m(2) per day on days 1-21 and cisplatin 60 mg/m(2) on day 8 of every 5-week cycle. Gastrectomy was restricted to D1 lymphadenectomy without any resection of metastatic lesions. The primary endpoint was overall survival, analysed by intention to treat. This study is registered with UMIN-CTR, number UMIN000001012.

FINDINGS

Between Feb 4, 2008, and Sept 17, 2013, 175 patients were randomly assigned to chemotherapy alone (86 patients) or gastrectomy followed by chemotherapy (89 patients). After the first interim analysis on Sept 14, 2013, the predictive probability of overall survival being significantly higher in the gastrectomy plus chemotherapy group than in the chemotherapy alone group at the final analysis was only 13·2%, so the study was closed on the basis of futility. Overall survival at 2 years for all randomly assigned patients was 31·7% (95% CI 21·7-42·2) for patients assigned to chemotherapy alone compared with 25·1% (16·2-34·9) for those assigned to gastrectomy plus chemotherapy. Median overall survival was 16·6 months (95% CI 13·7-19·8) for patients assigned to chemotherapy alone and 14·3 months (11·8-16·3) for those assigned to gastrectomy plus chemotherapy (hazard ratio 1·09, 95% CI 0·78-1·52; one-sided p=0·70). The incidence of the following grade 3 or 4 chemotherapy-associated adverse events was higher in patients assigned to gastrectomy plus chemotherapy than in those assigned to chemotherapy alone: leucopenia (14 patients [18%] vs two [3%]), anorexia (22 [29%] vs nine [12%]), nausea (11 [15%] vs four [5%]), and hyponatraemia (seven [9%] vs four [5%]). One treatment-related death occurred in a patient assigned to chemotherapy alone (sudden cardiopulmonary arrest of unknown cause during the second cycle of chemotherapy) and one occurred in a patient assigned to chemotherapy plus gastrectomy (rapid growth of peritoneal metastasis after discharge 12 days after surgery).

INTERPRETATION

Since gastrectomy followed by chemotherapy did not show any survival benefit compared with chemotherapy alone in advanced gastric cancer with a single non-curable factor, gastrectomy cannot be justified for treatment of patients with these tumours.

FUNDING

The Ministry of Health, Labour and Welfare of Japan and the Korean Gastric Cancer Association.

Manual Ambidexterity Predicts Robotic Surgical Proficiency

BACKGROUND

The manual dexterity of a surgeon is known to be related with surgical proficiency. Recently, as an objective measurement of surgical skills, inanimate methods using several types of simulators have been introduced. Using these simulators, we aimed to investigate the impact of manual dexterity on laparoscopic and robotic surgical proficiency.

MATERIALS AND METHODS

Fellow surgeons, surgical residents, and medical students (n = 32) participated in this study. For the measurement of dexterity, the sums and differences of the right and left hand performance times for the Grooved Pegboard Test were used as an index of dexterity speed and ambidexterity, respectively. The performance times during three sessions of laparoscopic suturing using a D-box trainer and the performance scores during three sessions using two robotic suturing programs with different degrees of difficulty provided by the da Vinci® Skills Simulator™ (Intuitive Surgical Inc., Sunnyvale, CA) were analyzed according to the measured manual dexterity.

RESULTS

Manual dexterity was not a significant factor for performance time during laparoscopic suturing, which was more influenced by participants' surgical experiences. In robotic suturing, the performance score was impacted significantly by manual dexterity in terms of ambidexterity rather than dexterity speed. For an easy robotic suturing task, the gap of proficiency between the lower and higher ambidexterity groups was decreased successively with each of the three sessions. However, that gap in cases with a difficult task was maintained consistently throughout all three sessions.

CONCLUSIONS

The degree of ambidexterity was an initial predictor for proficiency with simulated robotic suture. However, this relation could be lessened through a few sessions of training, although for a more difficult task further repetitions would be needed.

Efficacy of Gastric Balloon Dilatation and/or Retrievable Stent Insertion for Pyloric Spasms after Pylorus-Preserving Gastrectomy: Retrospective Analysis

Purpose

We retrospectively investigated the feasibility and clinical efficacy of balloon dilatation and subsequent retrievable stent insertion, when necessitated, for pyloric spasms after pylorus-preserving gastrectomy (PPG).

Materials and Methods

Forty-five patients experiencing pyloric spasms after PPG underwent fluoroscopic balloon dilations to alleviate obstructive symptoms due to delayed gastric emptying. Patients showing poor response to balloon dilation underwent subsequent retrievable stent insertion. Safety of the procedures was analyzed, and subjective symptoms and objective signs of pyloric spasms were analyzed and compared before and after treatment.

Results

Thirty-three patients (73.3%, 33/45) showed good response to balloon dilatation requiring no further treatment (balloon group). Conversely, 12 patients (26.7%, 12/45) showed poor or no response after balloon dilation requiring subsequent stent insertion (stent group). Balloon dilations and/or stent insertions were safely performed in all patients except one patient who suffered a transmural tear after balloon dilatation. In both groups, mean subjective symptom score was significantly improved and mean pyloric canal-to-height of the adjacent vertebral body ratio was significantly increased after the procedures (P <.05).

Conclusion

Balloon dilation is a safe and effective treatment for patients with pyloric spasms after PPG. In patients refractory to balloon dilations, retrievable stent placement can be a safe alternative tool.

Long-Term Surgical Outcome of 1057 Gastric GISTs According to 7th UICC/AJCC TNM System: Multicenter Observational Study From Korea and Japan

The aim of this study was to evaluate the treatment and prognosis of gastric gastrointestinal stromal tumors (GISTs) according to the 7th UICC/AJCC tumor-node-metastasis (TNM) system and the modified National Institutes of Health (NIH) risk classification. The study cohort consisted of 1057 patients with gastric GIST who underwent surgery between January 2000 and December 2007 from 13 institutions in Korea and 2 in Japan. Clinicopathologic characteristics, surgical outcomes, recurrence, and 5-year recurrence-free survival were evaluated.The mean age of the patients was 58.6 years. Thirty patients (2.8%) had distant metastasis preoperatively. Median tumor size was 4.0 cm. Complete resection (R0 resection) was achieved in 1018 patients (96.3%). Eighty-six patients (8.1%) had postoperative complications, and 2 patients (0.2%) died within 30 days after surgery. According to the 7th UICC/AJCC TNM system, 5-year recurrence-free survival rates were 95% to 99% in stage I, 94.1% in stage II, 74.1% in stage IIIA, 48.6% in stage IIIB, and 50.0% in stage IV patients. On survival analysis of high-risk patients according to the TNM system, the 5-year recurrence-free survival rates were 91.6% in stage II, 74.1% in stage IIIA, and 48.6% in stage IIIB patients. Independent factors of recurrence following surgery for gastric GIST were gender, tumor size, mitotic count, and radicality on multivariate analysis.The treatment outcome and prognosis of gastric GIST in Korea and Japan seem more favorable compared to those in Western countries. Compared to the modified NIH risk classification, the 7th UICC/AJCC TNM system is more reflective of the 5-year recurrence-free survival of patients with gastric GIST.

Clinical Outcome of Modified Laparoscopy-Assisted Proximal Gastrectomy Compared to Conventional Proximal Gastrectomy or Total Gastrectomy for Upper-Third Early Gastric Cancer with Special References to Postoperative Reflux Esophagitis

Purpose

This study evaluated the functional and oncological outcomes of proximal gastrectomy (PG) in comparison with total gastrectomy (TG) for upper-third early gastric cancer (EGC).

Materials and Methods

The medical records of upper-third EGC patients who had undergone PG (n=192) or TG (n=157) were reviewed. The PG group was further subdivided into patients who had undergone conventional open PG (cPG; n=157) or modified laparoscopy-assisted PG (mLAPG; n=35). Patients who had undergone mLAPG had a longer portion of their intra-abdominal esophagus preserved than patients who had undergone cPG. Surgical morbidity, recurrence, long-term nutritional status, and the incidence of reflux esophagitis were compared between the groups.

Results

The rate of postoperative complications was significantly lower for PG than TG (16.7% vs. 31.2%), but the five-year overall survival rate was comparable between the two groups (99.3% vs. 96.3%). Postoperative levels of hemoglobin and albumin were significantly higher for patients who had undergone PG. However, the incidence of reflux esophagitis was higher for PG than for TG (37.4% vs. 3.7%; P<0.001). mLAPG was related to a lower incidence of reflux esophagitis after PG (P<0.001).

Conclusions

Compared to TG, PG showed an advantage in terms of postoperative morbidity and nutrition, and there was a comparable prognosis between the two procedures. Preserving the intra-abdominal esophagus may lower the incidence of reflux esophagitis associated with PG.

Serum VEGF-A and Tumor Vessel VEGFR-2 Levels Predict Survival in Caucasian but Not Asian Patients Undergoing Resection for Gastric Adenocarcinoma

BACKGROUND

Clinical trials of agents targeting the vascular endothelial growth factor A (VEGF-A) pathway in gastric adenocarcinoma (GA) suggest that these therapies may have varying efficacy in different races.

METHODS

VEGF-A in serum and/or VEGF receptor 2 (VEGFR-2) in CD31-positive tumor vessels (VEGFR-2/CD31) were measured in 118 Caucasians and 263 Asians who underwent gastric resection at two institutions and correlated with overall survival (OS). Blood was drawn before any treatment. Patients receiving neoadjuvant treatment were excluded from VEGFR-2 analysis.

RESULTS

Compared with Asians, Caucasians were older (mean age 66-73 vs 59-62 years), had more proximal tumors, and had more advanced TNM stage. In the VEGF-A cohort, Caucasians had a median VEGF-A level that was 95 % higher than that of Asians and a much higher standard deviation (88 ± 6.206 vs 45 ± 76 pg/ml, p < 0.001). The 5-year OS for patients with low versus high VEGF-A levels was 72 versus 43 % in Caucasians (p = 0.001) and 86 versus 77 % in Asians (p = 0.236). In the VEGFR-2 cohort, OS was worse in Caucasians with high VEGFR-2/CD31 levels (49 vs 73 %, p = 0.038), while there was no significant difference in OS in Asians (80 vs 90 %, p = 0.119). On multivariate analyses of significant prognostic factors (excluding treatment factors and margin status), serum VEGF-A and tumor VEGFR-2/CD31 levels were independent predictors of OS only in Caucasians.

CONCLUSIONS

In patients with resectable GA, VEGF-A and VEGFR-2/CD31 levels are independent predictors of OS in Caucasians but not in Asians, suggesting varying importance of this pathway in GA progression among different races.

Abstract 3115: miR-30a-5p functions as a tumor suppressor gene in gastric cancer

Gastric cancer (GC) is the second leading cause of cancer-related death. MicroRNAs(miRNAs) are an abundant class of negative gene regulator and regulate multiple gene targets. miRNAs control a wide range of biological functions such as cellular proliferation, differentiation and apoptosis. Moreover, many miRNAs are highly conserved, and their deregulation is often associated with human malignancies. The aims of this study are to determine the miR-30a functions as a tumor suppressor gene and to evaluate whether the miR-30a-5p is able to use the diagnostic or prognostic marker in GC. To identify the gastric tumor-associated miRNAs, miRNA microarray was performed using the gastric cancer tissues. Among them, miR-30a-5p was down-regulated in GC tissues compared to normal mucosa. qRT-PCR was employed to confirm the microarray results. MiR-30a-5p expression was frequently down-regulated in our GC cohort, (n = 55, P&lt;0.0001). To determine the miR-30a-5p biological functions in GC, miR-30a-5p mimic or inhibitor was treated in GC cell lines. Ectopic expression of miR-30a-5p decreased cell growth, migration capacity and colony formation in vitro. Some previous studies have elucidated that miR-30a-5p is associated with metastasis in some cancer types. Accordingly, we confirmed its expression in our GC cohort with lymph node metastasis (n = 13) using qRT-PCR. MiR-30a-5p was significantly down-regulated in lymph node metastasis tissues than normal or tumor tissues. Taken together, the miR-30a-5p expression was frequently down-regulated in GC and lymph node metastasis. In addition, the miR-30a-5p suppressed tumorigenesis. Therefore, we suggest that miR-30a-5p activation may be a useful strategy of GC patient therapy and it can serve as a diagnostic or prognostic marker for GC.

Citation Format: Jimin Min, Tae-su Han, Boram Choi, Keun Hur, Hyuk-Joon Lee, Han-Kwang Yang. miR-30a-5p functions as a tumor suppressor gene in gastric cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 3115. doi:10.1158/1538-7445.AM2015-3115

Novel method for hybrid endo-laparoscopic full-thickness gastric resection using laparoscopic transgastric suture passer device

BACKGROUND

Current surgical methods for partial gastric full-thickness resections (FTRs) are limited by long operative times and risk of gastric content spillage, especially for lesions located at the posterior wall. We propose a simplified hybrid approach to FTR with reduced risk of spillage.

METHODS

Resection margins were marked by endoscopic electrocautery to simulate a gastric lesion in the upper third of the posterior wall in eight pigs. A custom-made laparoscopic "suture passer" was made of a sharpened bendable dissecting forceps. Full-thickness sutures were alternatively passed from the serosa side with the suture passer through the gastric wall and grabbed endoluminally using an endoscopic grasper and vice versa. These transgastric sutures formed either a purse string (PS; n = 4) or a continuous horizontal mattress (HM; n = 4). Sutures were then fastened from the laparoscopic side, resulting in external outpouching of the lesion. The pouch was transected using 45-mm linear staplers. Operative time, resection margins, and number of staplers were evaluated.

RESULTS

The combined approach allowed one to precisely place the sutures around the pseudo lesions, despite the inflated stomach, and it included all target markings. PS and HM methods were similar regarding time for transgastric suture (780 s ± 219.1 s vs. 765 s ± 179.2 s, p = .885), resection margins (1.3 ± 1.0 cm vs. 0.8 ± 0.6 cm, p = .248), and number of staplers (3.8 ± 1.0 vs 3.3 ± 0.5, p = .405). Stapling time (600 s ± 189.7 s vs. 330 s ± 24.5 s, p = .028) was significantly shorter in the HM technique.

CONCLUSION

FTR with laparo-endoscopic transgastric suture application was feasible in the animal model. This technique allows one to achieve accurate resection margins with minimal risk of spillage.

Age and sex interactions in gastric cancer incidence and mortality trends in Korea

BACKGROUND

The incidence and mortality of gastric cancer have declined rapidly over the past few decades, but reverse trends in the young generation's differential between sexes in some races have been reported in recent years. To investigate whether this divergent trend can be observed in Korea, a country with the highest incidence in the world, age- and sex-specific incidence and mortality trends were evaluated.

METHODS

Gastric cancer incidence data for the years 1999-2010 and mortality data for the years 1983-2012 were obtained from the Korea Central Cancer Registry and National Statistical Office. Annual percentage changes were calculated by age group (20-39, 40-54, 55-69, 70-79) using Joinpoint regression analysis. Furthermore, age-period-cohort analysis was evaluated.

RESULTS

Overall age-standardized gastric cancer incidence in adults aged between 20 and 79 was declining at a nonsignificant average annual percentage change (AAPC) of -0.2 % in males and -0.4 % in females in Korea during 1999-2010. Mortality was steeper at a significant rate of -4.3 and -5.9 % in males and females, respectively. However, age-specific analysis revealed a flat (males 0.2 %, 95 % CI -0.5-0.6) or increasing incidence trend (females 1.7 %, 95 % CI 0.9-2.5) in the 40-54 age group. APC analysis confirmed the decreasing incidence and mortality trend mainly by the cohort effect.

CONCLUSIONS

The differential pattern between males and females in different age groups suggests a possible effect of detection by screening practice or a signal of the change in epidemiological factors in the incidence and mortality of gastric cancer that warrants further studies.

Unaided Stapling Technique for Pure Single-Incision Distal Gastrectomy in Early Gastric Cancer: Unaided Delta-Shaped Anastomosis and Uncut Roux-en-Y Anastomosis

Purpose

Intracorporeal anastomosis is the most difficult procedure during pure single-incision distal gastrectomy (SIDG) that affects its generalization. We introduced unaided delta-shaped anastomosis (uDelta), a novel anastomosis technique, for gastroduodenostomy after pure SIDG, and compared the results with those of previously reported Roux-en-Y anastomosis (RY).

Materials and Methods

Between March 2014 and March 2015, SIDG with D1+ lymph node dissection was performed for early gastric cancer through a 2.5-cm transumbilical incision without any additional port. uDelta was performed by the operator alone, without any intracorporeal assistance.

Results

uDelta was performed on 11 patents, and uncut RY was performed on 5-patients without open or multiport conversion. R0 resection was performed in all cases. No significant differences were observed in mean age and body mass index between patients who underwent uDelta or RY. Mean operation times were 214.5±36.2 minutes for uDelta and 240.8±65.9 minutes for RY, which was not significantly different. Reconstruction time for uDelta was shorter than that for RY, with marginal statistical significance (26.1±8.3 minutes vs. 38.0±9.1 minutes, P=0.05). There were no intraoperative transfusions, 30-day mortality, or anastomosis-related complications in either group. Average length of hospital stay was 8.2±1.9 days in the uDelta group and 7.2±0.8 days in the RY group (P=0.320).

Conclusions

After carefully considering indications, uDelta can be a feasible and can be a reproducible reconstruction method after SIDG in early gastric cancer.

Association between information provision and decisional conflict in cancer patients

BACKGROUND

In this study, we aimed to identify demographic and clinical variables that correlate with perceived information provision among cancer patients and determine the association of information provision with decisional conflict (DC).

PATIENTS AND METHODS

We enrolled a total of 625 patients with cancer from two Korean hospitals in 2012. We used the European Organization for Research and Treatment of Cancer (EORTC) quality-of-life questionnaire (QLQ-INFO26) to assess patients' perception of the information received from their doctors and the Decisional Conflict Scale (DCS) to assess DC. To identify predictive sociodemographic and clinical variables for adequate information provision, backward selective logistic regression analyses were conducted. In addition, adjusted multivariate logistic regression analyses were carried out to identify clinically meaningful differences of perceived level of information subscales associated with high DC.

RESULTS

More than half of patients with cancer showed insufficient satisfaction with medical information about disease (56%), treatment (73%), other services (83%), and global score (80%). In multiple logistic regression analyses, lower income and education, female, unmarried status, type of cancer with good prognosis, and early stage of treatment process were associated with patients' perception of inadequate information provision. In addition, Information about the medical tests with high DCS values clarity [adjusted odds ratio (aOR), 0.54; 95% confidence interval (CI) 0.30-0.97] and support (aOR, 0.53; 95% CI 0.33-0.85) showed negative significance. For inadequate information perception about treatments and other services, all 5 DCS scales (uncertainty, informed, values clarity, support, and effective decision) were negatively related. Global score of inadequate information provision also showed negative association with high DCS effective decision (aOR, 0.43; 95% CI 0.26-0.71) and DCS uncertainty (aOR, 0.46; 95% CI 0.27-0.77).

CONCLUSION

This study found that inadequate levels of perceived information correlated with several demographic and clinical characteristics. In addition, sufficient perceived information levels may be related to low levels of DC.

KIAA1324 Suppresses Gastric Cancer Progression by Inhibiting the Oncoprotein GRP78

Recent advances in genome and transcriptome analysis have contributed to the identification of many potential cancer-related genes. Furthermore, biological and clinical investigations of the candidate genes provide us with a better understanding of carcinogenesis and development of cancer treatment. Here, we report a novel role of KIAA1324 as a tumor suppressor in gastric cancer. We observed that KIAA1324 was downregulated in most gastric cancers from transcriptome sequencing data and found that histone deacetylase was involved in the suppression of KIAA1324. Low KIAA1324 levels were associated with poor prognosis in gastric cancer patients. In the xenograft model, KIAA1324 significantly reduced tumor formation of gastric cancer cells and decreased development of preformed tumors. KIAA1324 also suppressed proliferation, invasion, and drug resistance and induced apoptosis in gastric cancer cells. Through protein interaction analysis, we identified GRP78 (glucose-regulated protein 78 kDa) as a KIAA1324-binding partner. KIAA1324 blocked oncogenic activities of GRP78 by inhibiting GRP78-caspase-7 interaction and suppressing GRP78-mediated AKT activation, thereby inducing apoptosis. In conclusion, our study reveals a tumor suppressive role of KIAA1324 via inhibition of GRP78 oncoprotein activities and provides new insight into the diagnosis and treatment of gastric cancer.

A novel criterion for identifying metabolically obese but normal weight individuals using the product of triglycerides and glucose

OBJECTIVES

Metabolically obese but normal weight (MONW) individuals constitute a subgroup of normal weight individuals that display impaired insulin sensitivity with a higher risk of developing diabetes, cardiovascular disease and mortality. We aimed to propose a novel criterion for defining MONW by examining the usefulness and the cutoff value of the TyG index, a product of the levels of triglycerides and glucose, in identifying MONW individuals. In addition, the performance of this criterion in predicting the future incidence of diabetes was assessed.

SUBJECTS/METHODS

A total of 7541 non-diabetic, normal weight (body mass index ⩾18.5 and <25 kg m(-)(2)) subjects were selected from the Korea National Health and Nutrition Examination Survey conducted in 2009-2010. Another 3185 participants with follow-up studies were selected from a prospective community-based cohort study. The TyG index was calculated as ln(fasting triglycerides (mg dl(-1)) × fasting glucose (mg dl(-1))/2).

RESULTS

The levels of the TyG index paralleled the prevalence of metabolic syndrome and its components. The cutoff value of the TyG index that reflected MONW based on the receiver operating characteristics analysis was 8.82 for men and 8.73 for women, with the area under the curve values being 0.855 and 0.868, respectively. The sensitivity and the specificity were 84.2 and 77.6% in men and 69.1 and 89.4% in women, respectively. Individuals designated as MONW, who have a normal weight and TyG levels higher than cutoff, displayed a metabolically unhealthy phenotype and an approximately twofold higher risk of developing diabetes compared with metabolically healthy normal weight subjects.

CONCLUSIONS

We propose a simple diagnostic criterion of MONW, which might be used to discriminate subjects with a higher risk of metabolic diseases.

Lower serum zinc levels are associated with unhealthy metabolic status in normal-weight adults: The 2010 Korea National Health and Nutrition Examination Survey

AIM

This study investigated whether serum zinc concentration is associated with glucose tolerance, insulin resistance and metabolic health status in Korean adults.

METHODS

Subjects with available serum zinc levels were recruited from the fifth Korea National Health and Nutrition Examination Survey (KNHANESV) cohort. Those in the highest quartile on homoeostasis model assessment for insulin resistance (HOMA-IR) and with a body mass index (BMI) of 18.5-25kg/m(2) were classified as metabolically obese and normal weight (MONW).

RESULTS

A total of 1813 subjects with a mean age of 45.2±0.5 years and a mean BMI of 24.01±0.11kg/m(2) were enrolled. Those in the lower serum zinc quartiles exhibited higher levels of fasting blood glucose and insulin resistance indices compared with those in the higher quartiles. However, these associations were positive only in normal-weight subjects. Those categorized as MONW exhibited significantly lower serum zinc levels than the metabolically healthy and normal weight (MHNW) subjects (131.6±3.0μg/dL vs 141.7±2.8μg/dL, respectively; P=0.0026), whereas serum zinc levels did not differ according to metabolic health in obese subjects. The odds ratio for being categorized as MONW was 4.12 (95% CI: 1.75, 9.72) among those in the lowest serum zinc quartile compared with those in the highest quartile even after adjusting for possible confounding factors.

CONCLUSION

Lower serum zinc levels were associated with unhealthy metabolic status in normal-weight adults. Further prospective studies are required to define the role of zinc in metabolic health.

Overexpression of Plasminogen Activator Inhibitor-1 in Advanced Gastric Cancer with Aggressive Lymph Node Metastasis

Purpose

The purpose of this study is to investigate differentially expressed genes using DNA microarray between advanced gastric cancer (AGC) with aggressive lymph node (LN) metastasis and that with a more advanced tumor stage but without LN metastasis.

Materials and Methods

Five sample pairs of gastric cancer tissue and normal gastric mucosa were taken from three patients with T3N3 stage (highN) and two with T4N0 stage (lowN). Data from triplicate DNA microarray experiments were analyzed, and candidate genes were identified using a volcano plot that showed ≥ 2-fold differential expression and were significant by Welch's t test (p < 0.05) between highN and lowN. Those selected genes were validated independently by reverse-transcriptase–polymerase chain reaction (RT-PCR) using five AGC patients, and tissue-microarray (TMA) comprising 47 AGC patients.

Results

CFTR, LAMC2, SERPINE2, F2R, MMP7, FN1, TIMP1, plasminogen activator inhibitor-1 (PAI-1), ITGB8, SDS, and TMPRSS4 were commonly up-regulated over 2-fold in highN. REG3A, CD24, ITLN1, and WBP5 were commonly down-regulated over 2-fold in lowN. Among these genes, overexpression of PAI-1 was validated by RT-PCR, and TMA showed 16.7% (7/42) PAI-1 expression in T3N3, but none (0/5) in T4N0 (p=0.393).

Conclusion

DNA microarray analysis and validation by RT-PCR and TMA showed that overexpression of PAI-1 is related to aggressive LN metastasis in AGC.

MicroRNA-29c mediates initiation of gastric carcinogenesis by directly targeting ITGB1

OBJECTIVE

Gastric cancer (GC) remains difficult to cure due to heterogeneity in a clinical challenge and the molecular mechanisms underlying this disease are complex and not completely understood. Accumulating evidence suggests that microRNAs (miRNAs) play an important role in GC, but the role of specific miRNAs involved in this disease remains elusive. We performed next generation sequencing (NGS)-based whole-transcriptome profiling to discover GC-specific miRNAs, followed by functional validation of results.

DESIGN

NGS-based miRNA profiles were generated in matched pairs of GCs and adjacent normal mucosa (NM). Quantitative RT-PCR validation of miR-29c expression was performed in 274 gastric tissues, which included two cohorts of matched GC and NM specimens. Functional validation of miR-29c and its gene targets was undertaken in cell lines, as well as K19-C2mE and K19-Wnt1/C2mE transgenic mice.

RESULTS

NGS analysis revealed four GC-specific miRNAs. Among these, miR-29c expression was significantly decreased in GC versus NM tissues (p<0.001). Ectopic expression of miR-29c mimics in GC cell lines resulted in reduced proliferation, adhesion, invasion and migration. High miR-29c expression suppressed xenograft tumour growth in nude mice. Direct interaction between miR-29c and its newly discovered target, ITGB1, was identified in cell lines and transgenic mice. MiR-29c expression demonstrated a stepwise decrease in wild type hyperplasia-dysplasia cascade in transgenic mice models of GC.

CONCLUSIONS

MiR-29c acts as a tumour suppressor in GC by directly targeting ITGB1. Loss of miR-29c expression is an early event in the initiation of gastric carcinogenesis and may serve as a diagnostic and therapeutic biomarker for patients with GC.

Preoperative serum VEGF-A levels to predict survival for Caucasian and Asian patients undergoing resection for gastric adenocarcinoma

81

Background: Clinical trials in gastric adenocarcinoma (GC) patients of vascular endothelial growth factor A (VEGF-A) targeted therapies have suggested these therapies may be more effective in Caucasians (CA) than in Asians (AS). Methods: Levels of VEGF-A in serum were measured in CA and AS treated at two institutions prior to potentially curative surgical resection for GC, and levels were correlated with overall survival (OS). Results: There were significant differences in CA (n=118) and AS (n=115) in terms of age (median 66 vs. 59), use of neoadjuvant (52% vs. 14%) and adjuvant therapy (27% vs. 18%), tumor location (58% upper/GE junction vs. 80% distal/middle), Lauren classification (57% vs. 46% intestinal), and TNM status (65% stage II or III vs. 55% stage I). CA had a median VEGF-A levels that was 95% higher than that of AS as well as a much higher standard deviation (88.1 + 6206 vs. 45.2 + 76.3 pg/ml, p<0.001). CA with proximal/nondiffuse tumors had significantly higher VEGF-A levels than those with distal/nondiffuse or diffuse tumors (median 120 vs. 71 and 50 pg/ml; p=0.016). The 5-year OS for CA with low vs. high VEGF-A levels was 72.4% vs. 43.4% (p=0.001). In AS, there was no significant difference in 5-year OS according to VEGF-A level (77.4%% vs.85.6%, p=0.236). On multivariate analysis, tumor size, location, grade, N stage, and serum VEGF-A level were independent predictors of OS in CA. Conclusions: In patients with resectable GC, higher circulating VEGF-A levels are independently associated with decreased OS in CA but AS, suggesting varying importance of this angiogenic factor in GC progression among different races.

Morbidity and mortality after laparoscopy-assisted and open distal gastrectomy for stage I gastric cancer: Results from a multicenter randomized controlled trial (KLASS-01)

4

Background: Laparoscopy assisted distal gastrectomy (LADG) is widely performed for gastric cancer in Eastern countries, although large scale prospective data are still lacking. We conducted a phase III, multicenter randomized controlled trial (KLASS-01) to compare the short and long term outcomes of LADG versus open distal gastrectomy (ODG) in patients with clinical stage I gastric cancer in Korea. Methods: The primary end point was 5-year overall survival. The morbidity within 30 postoperative days and the surgical mortality were compared to evaluate the safety of LADG as a secondary end point. A total of 1,416 patients were randomly assigned to the LADG group (n = 705) or the ODG group (n = 711) between Feb 1, 2006 and Aug 31, 2010. Results: 1,256 were eligible for per protocol (PP) analysis (644 and 612, respectively). The overall complication rate was significantly lower in the LADG group (LADG vs. ODG; 13.0% vs. 19.9%, P =.001). In detail, the wound complication rate of the LADG group was significantly lower than that of the ODG group (3.1% vs. 7.7%, P <.001). The major intra-abdominal complication (7.6% vs. 10.3%, P =.095) and mortality rates (0.6% vs. 0.3%, P =.450) were similar between groups. Modified intention-to-treat analysis showed similar results with PP analysis. Conclusions: LADG for patients with clinical stage I gastric cancer is safe and has a benefit of lower occurrence of wound complication compared with conventional ODG. Clinical trial information: NCT00452751.

Association of superior oblique muscle volumes with the presence or absence of the trochlear nerve on high-resolution MR imaging in congenital superior oblique palsy

BACKGROUND AND PURPOSE

Congenital superior oblique palsy is known to relate to trochlear nerve absence and a variable degree of superior oblique muscle hypoplasia. The purpose of this study was to determine whether superior oblique muscle volume predicts trochlear nerve absence in congenital superior oblique palsy.

MATERIALS AND METHODS

A retrospective study of high-resolution MR imaging to evaluate the presence of the trochlear nerve and to measure superior oblique muscle areas and volumes with the image analysis tools of a PACS was performed in 128 consecutive patients with unilateral congenital superior oblique palsy and 34 age-matched healthy controls.

RESULTS

Of the 128 patients with congenital superior oblique palsy, 88 had an ipsilateral trochlear nerve absence (absent group) and 40 had both trochlear nerves (present group). In patients with congenital superior oblique palsy, the paretic side superior oblique muscle volume was significantly smaller compared with the normal side only in the absent group (P < .001). The left and right side superior oblique muscle volumes were not significantly different in controls (P = .750), and the paretic and normal side superior oblique muscle volumes were not significantly different in the present group (P = .536). The cutoff value of the paretic/normal side superior oblique muscle volume ratio for diagnosing trochlear nerve absence was ≤0.75 (sensitivity 98.9%, specificity 95.0%) in patients with congenital superior oblique palsy.

CONCLUSIONS

The ratio of paretic/normal side superior oblique muscle area and volume has an excellent predictability in diagnosing trochlear nerve absence in congenital superior oblique palsy.

Evaluation of the novel near-infrared fluorescence tracers pullulan polymer nanogel and indocyanine green/γ-glutamic acid complex for sentinel lymph node navigation surgery in large animal models

BACKGROUND

This study aimed to examine tracers designed to overcome the disadvantages of indocyanine green (ICG), which disperses quickly to multiple lymph nodes, using a near-infrared (NIR) imaging system in animal models.

METHODS

Diluted ICG, ICG/poly-γ-glutamic acid (PGA) complex, and IRDye900-conjugated pullulan-cholesterol nanoprobe "near-infrared polynagogel" (NIR-PNG) were injected into the stomachs of dogs and pigs, and the patterns of dispersion were observed using an NIR imaging system. To compare retention times, fluorescence signals were evaluated in the stomach and small bowel of animals 1 week after injection.

RESULTS

A diluted concentration (~0.1 mg/ml) of ICG was optimal for NIR imaging compared with the conventional concentration (5 mg/ml) for visual inspection. When injected into the stomach, the signals of ICG and ICG/PGA complex were relatively large at the injection site, and signals were detected at multiple sentinel nodes and lymph nodes beyond them. The NIR-PNG signal intensity was relatively small at the injection site and limited to only one sentinel node with no additional node. When evaluated 1 week after injection, only the NIR-PNG signal was detected in the canine stomach, and the signal intensity at the lymph nodes of the porcine small bowel was the highest with NIR-PNG, followed by ICG/PGA complex and finally ICG.

CONCLUSION

NIR-PNG showed the best characteristics of less dispersion and longer retention in the sentinel nodes, and ICG/PGA complex remained longer than diluted ICG. These tracers could potentially be used as optimal tracers for sentinel node navigation surgery in gastric cancer.

The value of postoperative serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels for the early detection of gastric cancer recurrence after curative resection

PURPOSE

This study aimed to evaluate the value of serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels to detect gastric cancer recurrence.

MATERIALS AND METHODS

We retrospectively reviewed 154 patients who developed recurrence within 2 years after curative gastric cancer surgery and analyzed the relationship between postoperative CEA and CA19-9 levels and recurrence. We readjusted the cut-off values to improve the detection of recurrence. Subgroup analysis according to clinicopathologic variables was performed to further investigate the relationship between recurrence and CEA and CA19-9 levels.

RESULTS

The sensitivity and specificity for elevated CEA levels to detect recurrence were 40.6% and 89.5%, respectively, and those for CA19-9 were 34.2% and 93.6%, respectively. The sensitivity and specificity for elevation of either tumor marker were 54.3% and 84.0%, respectively; those for elevation of both tumor markers were 19.2% and 98.4%, respectively. By readjusting the cut-off values from 5.0 ng/ml to 5.2 ng/ml for CEA and from 37.00 U/ml to 30.0 U/ml for CA19-9, the sensitivity was increased from 34.2% to 40.2% for CA19-9, while there was no increase in sensitivity for CEA. In subgroup analysis, the sensitivity of CEA was higher in patients with elevated preoperative CEA levels than in patients with normal preoperative CEA levels (86.7% versus 33.7%; P<0.001). Furthermore, the sensitivity of CA19-9 was higher in patients with elevated preoperative CA19-9 levels than in patients with normal preoperative CA19-9 levels (82.61% versus 26.83%; P<0.001).

CONCLUSIONS

CEA and/or CA19-9 measurement with the readjusted cut-off values allows for more effective detection of gastric cancer recurrence.

Homozygous deletions at 3p22, 5p14, 6q15, and 9p21 result in aberrant expression of tumor suppressor genes in gastric cancer

Homozygous deletion is a frequent mutational mechanism of silencing tumor suppressor genes in cancer. Therefore, homozygous deletions have been analyzed for identification of tumor suppressor genes that can be utilized as biomarkers or therapeutic targets for cancer treatment. In this study, to elucidate potential tumor suppressor genes involved in gastric cancer (GC), we analyzed the entire set of large homozygous deletions in six human GC cell lines through genome- and transcriptome-wide approaches. We identified 51 genes in homozygous deletion regions of chromosomes and confirmed the deletion frequency in tumor tissues of 219 GC patients from The Cancer Genome Atlas database. We evaluated the effect of homozygous deletions on the mRNA level and found significantly affected genes in chromosome bands 9p21, 3p22, 5p14, and 6q15. Among the genes in 9p21, we investigated the potential tumor suppressive effect of KLHL9. We demonstrated that ectopic expression of KLHL9 inhibited cell proliferation and tumor formation in KLHL9-deficient SNU-16 cell line. In addition, we observed that homozygous focal deletions generated truncated transcripts of TGFBR2, CTNNA1, and STXBP5. Ectopic expression of two kinds of TGFBR2-reverse GADL1 fusion genes suppressed TGF-β signaling, which may lead to the loss of sensitivity to TGF-β tumor suppressive activity. In conclusion, our findings suggest that novel tumor suppressor genes that are aberrantly expressed through homozygous deletions may play important roles in gastric tumorigenesis.

Obesity at adolescence and gastric cancer risk

BACKGROUND AND OBJECTIVE

During the last few decades, prevalence of obesity has risen rapidly worldwide, markedly in children and adolescents. Epidemiologic studies have associated obesity to several cancer types, yet little is known for the effect of early life exposure to obesity on cancer risk in later life, especially in gastric cancer. Thus, the present study aimed to investigate the association of body mass index (BMI) of adolescence and the risk of gastric cancer.

METHODS

A multicenter case-control study was conducted between 2010 and 2014 in Korea with 1,492 incident gastric cancer cases and 1,492 controls matched by age and sex. The BMI at age 18 was calculated by using weight and height from questionnaire. The association with the risk of gastric cancer was evaluated using odds ratios by logistic regression model adjusted for potential confounding factors.

RESULTS

Compared with BMI 21.75 kg/m(2), higher BMI at age 18 was associated with higher risk of gastric cancer showing a nonlinear, threshold effect. Statistically significant odds ratio was observed in men with BMI higher than 25.3 kg/m(2) (OR 1.13, 95 % CI 1.01-1.27) and in women with BMI 25.3 kg/m(2) and above (OR 1.25, 95 % CI 1.01-1.55).

CONCLUSION

Similar to some other cancer types, overweight or obese in adolescence was found to be associated with the increased risk of gastric cancer. The results imply for stratified approach of tactics in prevention of gastric cancer in different population.

Comparison of Surgical Outcomes of Robot-Assisted and Laparoscopy-Assisted Pylorus-Preserving Gastrectomy for Gastric Cancer: A Propensity Score Matching Analysis

BACKGROUND

The three-dimensional view and articulating devices in robot system might have a benefit performing the delicate procedure of pylorus-preserving gastrectomy. This study was conducted to evaluate the feasibility and safety of robot-assisted pylorus-preserving gastrectomy (RAPPG) and to compare the perioperative outcomes and oncologic safety between RAPPG and laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) for middle-third early gastric cancer.

METHODS

Between June 2008 and December 2013, we retrospectively collected data of 68 patients with RAPPG and propensity score matched 68 patients with LAPPG for the treatment of early gastric cancer at Seoul National University Hospital. The covariates for propensity score matching were: age, sex, American Society of Anesthesiologists score, body mass index, and operators. Clinicopathologic characteristics and surgical outcomes were compared between the two groups.

RESULTS

All RAPPG cases were performed successfully without open or laparoscopic conversion. Patient demographics and perioperative outcomes did not differ between the two groups except in operation time (258.3 vs. 193.9 min; P < 0.001). There was no significant difference in complication rates between the two groups (19.1 vs. 22.1 %; P = 0.671). The mean number of examined lymph nodes (33.4 vs. 36.5; P = 0.153), and the mean number of lymph nodes at each station was not different between the two groups.

CONCLUSIONS

RAPPG can be a safe treatment option for middle-third early gastric cancer in terms of surgical complications and oncologic outcomes. However, RAPPG has no benefit over LAPPG in this study.