Correlation of pathological complete response with survival after neoadjuvant chemotherapy in gastric or gastroesophageal junction cancer treated with radical surgery: A meta-analysis

ypT0 gastric carcinoma after preoperative chemotherapy: a unique status according to AJCC 8th edition cancer staging system

Background

American Joint Committee on Cancer (AJCC) recently had published 8th edition staging system, in which a separate staging system was proposed for gastric cancers those received preoperative therapy (ypStage), however ypT0 was not included. The aim of this study was to propose the inclusion of ypT0 into the new staging classification.

Methods

We collected data of gastric cancer patients who underwent gastrectomy after preoperative chemotherapy in the First Affiliated Hospital of Zhejiang University (2004–2015). Kaplan-Meier survival estimations and log-rank tests were performed to compare survival.

Results

314 patients were enrolled in this study according to inclusion and exclusion criteria. The 5-year overall survival (OS) rate of all patients was 53.5% and the survival estimation was well discriminated by ypstage (P<0.001). Twenty-five patients were identified achieving pathological complete regression in primary lesion (ypT0), in which there were 16 pCR patients and 9 ypT0N+ patients. The 5-year OS of pCR patients was 93.8%, which was not better than ypstage I with 5-year OS of 97.5% (P=0.507). Meanwhile, ypT0N+ patients’ 5-year OS was 66.7%, which was significantly shorter than those with ypstage I (P=0.002), but no statistical difference from ypstage II with 5-year OS of 71.6% (P=0.583).

Conclusions

Complete pathological regression of primary lesion (ypT0) was a predictor for long-term outcomes. pCR and ypT0N+ patients might be considered for inclusion in the ypstage I and ypstage II group respectively.

Vortioxetine induces apoptosis and autophagy of gastric cancer AGS cells via the PI3K/AKT pathway

Vortioxetine is a potent antagonist of the 5‐hydroxytryptamine receptor and serotonin transporter and has been reported to function as an antidepressant in the treatment of major depressive disorder. However, its antitumor effects remain unclear. Here, we examined whether vortioxetine affects the characteristics of GC cells. Cell viability was measured by a colony formation assay and, in addition, cell invasion, migration and apoptosis assays were performed with a transwell assay and a flow cytometry assay. Protein levels were measured by western blotting. We found that vortioxetine inhibited the proliferation, invasion and migration abilities of AGS cells. Additionally, vortioxetine could induce apoptosis and autophagy by increasing the levels of Bax, active caspase‐3/‐9, Beclin‐1 and light chain 3, as well as by downregulating Bcl‐2 and P62. Further investigations indicated that vortioxetine regulated apoptosis and autophagy via activation of the phosphoinositide 3‐kinase/AKT pathway. Taken together, our data suggest that vortioxetine has cytotoxic effects against GC AGS cells as a result of inhibiting proliferation, invasion and migration, as well as by inducing apoptosis and autophagy through the phosphoinositide 3‐kinase/AKT pathway.

The Effect of Obesity on Response to Neoadjuvant Therapy in Locally Advanced Gastric Cancer

Introduction:

The effect of obesity on response to neoadjuvant chemotherapy (NACT) remains unknown. We aimed to investigate the effect of obesity on response to NACT and survival in locally-advanced gastric cancer (GC).

Methods:

From 2010 to 2019, 142 GC patients with clinical stage III disease who underwent curative surgery after NACT were enrolled. Patients were divided into 3 groups according to body mass index (BMI) as follows; BMI < 25 kg/m², BMI = 25-30 kg/m², and BMI > 30 kg/m². The Mandard tumor regression grading system was used for tumor regression grade (TRG).

Results:

Of the 142 GC patients, 45(31.7%) were female. The median age was 58 years. BMI was < 25 kg/m² in 60 (42.3%) patients, 25-30 kg/m2 in 44 (31%) patients, and > 30kg/m² in 38 (26.8%) patients. The numbers of patients with TRGI-II, TRGIII, and TRGIV-V were 35 (24.6%), 44 (31%), and 63 (44.4%), respectively. There was no statistically significant difference among BMI groups in terms of disease-free survival (DFS) and overall survival (OS) (p = 0.919 and p = 0.398, respectively). According to TRG groups; mDFS was 46 months in TRG I-II, 28 months in TRG III, and 18 months in TRG IV-V (p<0.001). In multivariate analysis, presence of perineural invasion and lymphovascular invasion were the factors affecting TRG.

Conclusion:

In our study, we found that pre-treatment obesity did not affect the TRG in clinical stage III GC patients. However, a better TRG status was associated with improved survival.

Emerging Multimodality Approaches to Treat Localized Esophageal Cancer

Esophageal cancer has a poor prognosis, with 5-year survival rates ranging from 20% to 35% in the nonmetastatic setting. Despite advances in surgical techniques and optimization of chemoradiotherapy regimens, overall survival benefits have been incremental at best. Esophageal cancer requires a concerted multidisciplinary approach, perhaps more so than any other tumor type given the integral role played by the esophagus in maintaining calorific intake and the propensity for early spread through the lymphatics. This review describes the latest in surgical techniques to minimize postoperative complications and examines previous and ongoing systemic therapy approaches. Strategies that harness a patient's own immune system hold great promise, and shifting checkpoint inhibitors from the metastatic setting to the neoadjuvant/adjuvant setting is currently being evaluated in phase II and III clinical trials. In addition, a much better understanding of the interplay between tumors and their immune microenvironment is clearly needed to better judge how best to engage each patient's immune system, and there will be likely demonstrable differences between early-stage tumors and metastatic disease. This review highlights emerging data, which demonstrate that, in addition to The Cancer Genome Atlas classification of esophageal squamous cell carcinoma having a distinct molecular makeup compared with esophageal adenocarcinoma, there are also differing responses to PD-1 inhibitors. Histology and the underlying immune milieu may have important ramifications for the management of localized disease in the future, above and beyond PD-L1 expression, microsatellite instability status, and tumor mutational burden.

FLOT Neoadjuvant Chemotherapy Followed by Laparoscopic D2 Gastrectomy in the Treatment of Locally Resectable Advanced Gastric Cancer

BACKGROUND

The prognosis of patients with advanced gastric cancer remains unsatisfactory, highlighting the need for improved therapeutic strategies. We analyzed 23 resectable advanced gastric cancer patients who received FLOT followed by laparoscopic gastrectomy with D2 lymphadenectomy to evaluate the efficacy and safety.

METHODS

Patients aged 18-75 years with gastric adenocarcinoma (stage cT3-4 and/or N + M0) underwent neoadjuvant FLOT therapy (four preoperative and four postoperative 2-week cycles) at Shanghai East Hospital. Laparoscopic gastrectomy was scheduled 3-4 weeks after completion of the last cycle of preoperative chemotherapy. The type of surgical procedure was determined by the location and extent of the primary tumor.

RESULTS

23 patients were reviewed in the study. 20 patients (81.2%) received four courses of FOLT therapy, while 3 patients (18.8%) received three courses of treatment. There were 3 (13.0%) complete responses, 13 (56.5%) partial responses, 4 (26.1%) of stable disease, and 1 (4.3%) of progressive disease. The clinical efficacy response rate was 69.6%. The R0 resection rate was 91.3%. Only one patient exhibited grade III postoperative complications. The pathologic complete remission was 13%. The common grade 3/4 adverse events from chemotherapy were leucopenia (17.4%), neutropenia (30.4%), anemia (13%), anorexia (13%), and nausea (17.4%). Postoperative complications occurred in 5 patients (26.1%). There was no treatment-related mortality or reoperation. The most reason for not completing chemotherapy was the patient's request.

CONCLUSIONS

These findings suggest that FLOT neoadjuvant chemotherapy, followed by laparoscopic D2 gastrectomy, is effective and safe in advanced, resectable advanced gastric cancer.

Correlation among postoperative uncertainty, social support, and quality of life in patients with esophageal cancer in a tertiary hospital

BACKGROUND

Esophageal cancer is one of the most common malignant tumors. It is easy to cause patients to change their dietary structure after surgery, which leads to decreased quality of life. The decrease of quality of life affects the patients' psychosocial mood to some extent, and the degree of social support is one of the important factors affecting the quality of life of cancer patients.

AIM

To investigate the correlation among the feeling of disease uncertainty, social support, and quality of life in patients with esophageal cancer after operation in a tertiary hospital.

METHODS

A total of 120 patients admitted to Yiwu Central Hospital of Zhejiang Province from February 2017 to September 2019 after esophageal cancer surgery were selected as study subjects. After admission, the patients were investigated and analyzed using the scales of disease uncertainty, social support status, and quality of life. SPSS 23.0 software was used to analyze the data, and the correlation between postoperative quality of life and social support was analyzed by multiple regression.

RESULTS

The disease uncertainty scores of patients with esophageal cancer were 68-126 (102.65 ± 8.76). Among the four dimensions, the score of uncertainty dimension was 3.56 ± 0.46, the complexity score was 2.87 ± 0.52, the score of unpredictability of prognosis was 3.12 ± 0.35, and the score of lack of information was 3.62 ± 0.34. The postoperative social support score of patients with esophageal cancer was 41.87 ± 8.96, which was significantly higher than the norm score (33.75 ± 4.12; P < 0.05). The scores of body function, role function, and overall health dimensions of the postoperative quality of life scale in patients with esophageal cancer were positively correlated with social support (r = 0.724, 0.602, and 0.654, respectively). Physical function and overall health were positively correlated with subjective support (r = 0.712, 0.625). Body function was positively correlated with objective support (r = 0.528). Role function and overall health were positively correlated with paired support utilization (r = 0.538, 0.526).

CONCLUSION

The overall postoperative quality of life of patients with esophageal cancer is positively correlated with three dimensions of social support, indicating that social support plays an important role in patients' quality of life.

Lymph node regression after neoadjuvant chemotherapy: A predictor of survival in gastric cancer

BACKGROUND AND OBJECTIVE

Neoadjuvant chemotherapy (nCMT) has been increasingly used in advanced gastric cancer (GC). However, the prognostic impact of tumor response remains unclear. This study aimed to evaluate if tumor response at the primary site and lymph nodes (LN) correlate with survival in GC patients after nCMT.

METHODS

Patients with gastric adenocarcinoma treated with nCMT followed by gastrectomy were evaluated. Residual tumor was graded from 0% to 100%, defining two groups: poor (PR) and major response (MR). LN regression rate (LNRR) was determined based on tumor/fibrosis examination at each LN and a cutoff value established by receiver operating characteristic curve.

RESULTS

Among 62 cases, 20 (32.2%) had MR and 42 (67.7%) PR. Smaller size, diffuse histology, lower ypT status and less advanced stage were associated with the MR group. Based on cutoff value of 57, 45.6% and 54.4% patients were classified as low-LNRR and high-LNRR. High-LNRR correlated with absence of venous, lymphatic and perineural invasion, and less advanced stage. Survival was equivalent between MR and PR (P = .956). High-LNRR had better disease-free survival (DFS) than low-LNRR (P < .001). In multivariate analysis, only LNRR associated with DFS.

CONCLUSION

High-LNRR associates with DFS in GC treated with nCMT. Response at the primary site does not correlate with survival.

Neoadjuvant checkpoint blockade for cancer immunotherapy

Cancer immunotherapies that target the programmed cell death 1 (PD-1):programmed death-ligand 1 (PD-L1) immune checkpoint pathway have ushered in the modern oncology era. Drugs that block PD-1 or PD-L1 facilitate endogenous antitumor immunity and, because of their broad activity spectrum, have been regarded as a common denominator for cancer therapy. Nevertheless, many advanced tumors demonstrate de novo or acquired treatment resistance, and ongoing research efforts are focused on improving patient outcomes. Using anti-PD-1 or anti-PD-L1 treatment against earlier stages of cancer is hypothesized to be one such solution. This Review focuses on the development of neoadjuvant (presurgical) immunotherapy in the era of PD-1 pathway blockade, highlighting particular considerations for biological mechanisms, clinical trial design, and pathologic response assessments. Findings from neoadjuvant immunotherapy studies may reveal pathways, mechanisms, and molecules that can be cotargeted in new treatment combinations to increase anti-PD-1 and anti-PD-L1 efficacy.

A Case of Advanced Gastric Cancer with Folfiri as a Preoperative Chemotherapy

Introduction

In advanced gastric cancer, preoperative chemotherapy is associated with survival benefit. FOLFIRI has demonstrated promising results in terms of survival and tolerance, especially in patients with poor performance status.

Case Presentation

A 59-year-old male, diagnosed with pT4bN2M0 gastric cancer, underwent gastrointestinal anastomosis and three cycles of EOX chemotherapy. Due to disease progression, he was switched to FOLFIRI regimen. After 12 cycles, the patient received a subtotal gastrectomy and D2 lymphadenectomy. Microscopic examination achieved pCR, and the patient has been surviving 34 months without recurrence. No severe toxicities of chemotherapy were recorded.

Conclusions

FOLFIRI might be a safe and effective option in neoadjuvant treatment for advanced gastric cancer among patients with poor performance status or progression after first-line chemotherapy.

Oxaliplatin, 5-Fluorouracil and Nab-paclitaxel as perioperative regimen in patients with resectable gastric adenocarcinoma: A GERCOR phase II study (FOXAGAST)

BACKGROUND

5-Fluorouracil (5-FU) and platinum-based perioperative chemotherapy is standard of care for resectable gastric adenocarcinoma (RGA). Nanoparticle albumin-bound (Nab-) paclitaxel is active in advanced disease but has never been evaluated in the perioperative setting. The objective was to evaluate the efficacy of Nab-paclitaxel in combination with FOLFOX for RGA patients.

METHODS

We performed a non-randomised, open-label, phase II study. RGA patients were assigned to receive neoadjuvant Nab-paclitaxel (150 mg/m²) and FOLFOX q2w for six cycles. Six additional post-operative cycles were kept at the investigator's discretion. The primary end-point was complete pathological response (tumour regression grade [TRG1]) rate. According to Fleming design, 49 patients were required to test H₀ (10% TRG1) and H₁ (25% TRG1). To reject H₀, TRG1 had to be achieved in 8 patients.

RESULTS

Forty-nine patients were included. Median number of neoadjuvant chemotherapy cycles was 6 (range, 3-6). Median dose intensity for Nab-paclitaxel, oxaliplatin and 5-FU was 96% (38-103%), 97% (47-103%) and 99% (50-112%), respectively. Surgery could not be performed in 5 (10.2%) patients. Tumour resection was R0 for 42 of 44 (95.5%) patients. Pathological review classified tumours as TRG1 to TRG5 for 8 (16.3%), 11 (22.5%), 4 (8.2%), 18 (36.7%) and 3 (6.1%) patients, respectively. Grade 3 or worse toxicities during neoadjuvant chemotherapy were non-febrile neutropenia (20.4%), nausea (8.2%), diarrhoea (8.2%) and neuropathy (6.1%). Of 44 patients, 14 (31.8%) experienced surgery-related complications and three (6.8%) died of surgical complications.

CONCLUSION

This regimen shows promising activity. Toxicity is manageable but a meaningful rate of surgical complications was observed. This strategy deserves investigation in phase III studies.

Neoadjuvant chemotherapy combined with laparoscopic surgery for treatment of advanced gastric cancer: Efficacy and impact on quality of life

AIM

To investigate the clinical effect of neoadjuvant chemotherapy combined with laparoscopic-assisted radical gastrectomy in treating advanced gastric cancer and the effect on the quality of life of patients.

METHODS

A retrospective analysis was performed of 104 cases of advanced gastric cancer admitted from February 2014 to November 2016 at Taizhou Hospital. According to whether the patients would like to undergo neoadjuvant chemotherapy or not, they were divided into an observation group (neoadjuvant chemotherapy plus laparoscopic surgery; n = 56) or a control group (direct laparoscopic-assisted radical gastrectomy; n = 48). Both groups were given six courses of XELOX chemotherapy after operation. Clinical efficacy, operation indexes, postoperative recovery, quality of life, adverse reactions, and recurrence or metastasis were compared between the two groups.

RESULTS

After neoadjuvant chemotherapy, the effective rate and disease control rate in the observation group were 48.21% and 92.45%, respectively. There was no significant difference in operative time, intraoperative blood loss, number of cases of conversion to open laparotomy, surgical excision range, number of cases of palliative surgery, or number of lymph nodes dissected between the two groups (P > 0.05). The R₀ resection rate in the observation group was significantly higher than that of the control group (85.71% vs 52.08%, P < 0.05). There was no significant difference in time to ambulation, time to anal exhaust, postoperative complications, or hospital stay between the two groups (P > 0.05). The KPS scores of the observation group at 3 and 6 months after chemotherapy were significantly higher than those of the control group (82.8 ± 6.9 vs 76.2 ± 5.1, 91.6 ± 8.1 vs 85.2 ± 7.3, P < 0.05). As of December 2017, the follow-up period ranged from 9 to 46 mo, and the median follow-up time was 24 mo. During the follow-up period, four patients died and ten patients developed recurrence or metastasis in the observation group. In the control group, 11 patients died and 19 developed recurrence or metastasis. There was a significant difference in the rates of death and recurrence/metastasis between the two groups (χ² = 5.210, 6.067, P < 0.05). Log-rank test analysis showed that the risk of death in the observation group was significantly lower than that of the control group (P < 0.05).

CONCLUSION

Neoadjuvant chemotherapy combined with laparoscopic radical gastrectomy for advanced gastric cancer has significant curative effects and can significantly improve the resection rate and quality of life, reduce recurrence and metastasis, and improve the survival of patients.