Nodal dissection for patients with gastric cancer: a randomised controlled trial

Oncological outcomes of function-preserving gastrectomy for early gastric cancer: a multicenter propensity score matched cohort analysis comparing pylorus-preserving gastrectomy versus conventional distal gastrectomy

OBJECTIVE

This study aimed to clarify the oncological safety of pylorus-preserving gastrectomy (PPG) compared with conventional distal gastrectomy (DG).

METHODS

From three institutions specializing in cancer, the medical records for a cohort of 2898 consecutive patients who had undergone DG (n = 2208) or PPG (n = 690) for clinical stage I gastric cancer between January 2006 and December 2012 were analyzed. A propensity score for each patient was estimated on the basis of 38 preoperative clinical and tumor-related factors. After propensity score matching had been done, 1004 patients (502 DG patients, 502 PPG patients) were included in the analysis. The overall survival, relapse-free survival, and occurrence of secondary gastric cancer were then compared. The median observation period was 48.6 months (range 1-109.8 months).

RESULTS

The 5-year overall survival rate was 98.4 % for the PPG group and 96.6 % for the DG group (hazard ratio 0.48, 95 % confidence interval 0.21-1.09, P = 0.07). The 3-year relapse-free survival rate was 99.5 % for the PPG group and 98.0 % for the DG group (hazard ratio 0.39, 95 % confidence interval 0.12-1.33, P = 0.12). Postoperative secondary gastric cancer was encountered in eight patients (1.6 %) in the PPG group and four patients (0.8 %) in the DG group. No significant differences in either overall survival, relapse-free survival, or the occurrence of secondary gastric cancer were observed between the two groups.

CONCLUSIONS

Given the adequate estimation of the clinical tumor stage, the oncological safety of PPG for clinical T1N0 gastric cancer in the middle portion of the stomach was comparable to that of DG.

Intraoperative radiotherapy: review of techniques and results

Intraoperative radiotherapy (IORT) is a technique that involves precise delivery of a large dose of ionising radiation to the tumour or tumour bed during surgery. Direct visualisation of the tumour bed and ability to space out the normal tissues from the tumour bed allows maximisation of the dose to the tumour while minimising the dose to normal tissues. This results in an improved therapeutic ratio with IORT. Although it was introduced in the 1960s, it has seen a resurgence of popularity with the introduction of self-shielding mobile linear accelerators and low-kV IORT devices, which by eliminating the logistical issues of transport of the patient during surgery for radiotherapy or building a shielded operating room, has enabled its wider use in the community.

Electrons, low-kV X-rays and HDR brachytherapy are all different methods of IORT in current clinical use. Each method has its own unique set of advantages and disadvantages, its own set of indications where one may be better suited than the other, and each requires a specific kind of expertise.

IORT has demonstrated its efficacy in a wide variety of intra-abdominal tumours, recurrent colorectal cancers, recurrent gynaecological cancers, and soft-tissue tumours. Recently, it has emerged as an attractive treatment option for selected, early-stage breast cancer, owing to the ability to complete the entire course of radiotherapy during surgery. IORT has been used in a multitude of roles across these sites, for dose escalation (retroperitoneal sarcoma), EBRT dose de-escalation (paediatric tumours), as sole radiation modality (early breast cancers) and as a re-irradiation modality (recurrent rectal and gynaecological cancers).

This article aims to provide a review of the rationale, techniques, and outcomes for IORT across different sites relevant to current clinical practice.

Gastric adenocarcinoma

Gastric cancers, with gastric adenocarcinoma (GAC) as the most common histological type, impose a considerable global health burden. Although the screening strategies for early detection have been shown to be successful in Japan and South Korea, they are either not implemented or not feasible in most of the world, leading to late diagnosis in most patients. Helicobacter pylori infection contributes to the development of many endemic GACs, and pre-emptive eradication or early treatment of this bacterial infection might provide effective primary prevention. GACs are phenotypically and genotypically heterogeneous. Localized (clinical stage I) GAC is best treated either endoscopically or with limited surgical resection, but clinical stage II or stage III tumours require multidisciplinary adjunctive approaches in addition to surgery. Although GAC is highly treatable in its early stages, advanced (clinical stage IV) GAC has a median survival of just ∼9-10 months. However, detailed molecular and immune profiling of GAC is yielding promise; early studies with immune checkpoint inhibitors suggest that GAC is amenable to immune modulation. Molecular studies have yielded a vast quantity of new information for potential exploitation. Nevertheless, advances against GACs have lagged compared with other tumours of similar incidence, and more research is necessary to overcome the obstacles to prolong survival.

Identification of circulating microRNA signatures as potential noninvasive biomarkers for prediction and prognosis of lymph node metastasis in gastric cancer

Circulating microRNAs (miRNAs) are emerging as novel noninvasive biomarkers for prediction of lymph node metastasis (LNM) in cancer. The aim of this study was to identify serum miRNA signatures for prediction and prognosis of LNM in gastric cancer (GC). MiSeq sequencing was performed for an initial screening of serum miRNAs in 10 GC patients with LNM, 10 patients without LNM and 10 healthy controls. Reverse transcription quantitative real-time PCR was applied to confirm concentration of candidate miRNAs using a training cohort (n = 279) and a validation cohort (n = 180). We identified a four-miRNA panel (miR-501-3p, miR-143-3p, miR-451a, miR-146a) by multivariate logistic regression model that provided high predictive accuracy for LNM with an area under the receiver operating characteristic curve (AUC) of 0.891 (95% CI, 0.840 to 0.930) in training set. Prospective evaluation of this panel revealed an AUC of 0.822 (95% CI, 0.758 to 0.875, specificity = 87.78%, sensitivity = 63.33%) in validation set. Moreover, Kaplan-Meier analysis showed that LNM patients with low miR-451a and miR-146a levels had worse overall survival (OS) (p < 0.05). In Cox regression analysis, miR-451a was independently associated with OS of LNM (p = 0.028). Our results suggested that use of serum miRNAs seems promising in estimating the probability GC patients harbor LNM and providing prognostic information for LNM.

miR-376c promotes carcinogenesis and serves as a plasma marker for gastric carcinoma

Gastric carcinoma is highly prevalent throughout the world. Understanding the pathogenesis of this disease will benefit diagnosis and resolution. Studies show that miRNAs are involved in the tumorigenesis of gastric carcinoma. An initial screening followed by subsequent validation identified that miR-376c is up-regulated in gastric carcinoma tissue and the plasma of patients with the disease. In addition, the urinary level of miR-376c is also significantly increased in gastric carcinoma patients. The plasma miR-376c level was validated as a biomarker for gastric carcinoma, including early stage tumors. The induction of miR-376c was found to enrich the proliferation, migration and anchorage-independent growth of carcinoma cells and, furthermore, the repression of the expression of endogenous miR-376c was able to reduce such oncogenic phenotypes. ARID4A gene is a direct target of miR-376c. Knockdown of endogenous ARID4A increased the oncogenicity of carcinoma cells, while ARID4A was found to be drastically down-regulated in tumor tissue. Thus, expression levels of miR-376c and ARID4A mRNA tended to be opposing in tumor tissue. Our results demonstrate that miR-376c functions by suppressing ARID4A expression, which in turn enhances the oncogenicity of gastric carcinoma cells. It seems likely that the level of miR-376c in plasma and urine could act as invaluable markers for the detection of gastric carcinoma.

Validation of a nomogram for selecting patients for chemotherapy after D2 gastrectomy for cancer

BACKGROUND

According to some guidelines for the management of gastric cancer, adjuvant chemotherapy is recommended for patients with pT3-4 or node-positive disease. The aim of this study was to define low- and high-risk groups in terms of survival, and to predict the benefit of adjuvant fluoropyrimidine plus oxaliplatin (F-OX) chemotherapy.

METHODS

Patients with pT3-4 or node-positive gastric cancer after gastrectomy with D2 lymphadenectomy between 2000 and 2013 were included. The performance of a previously published nomogram was assessed by discrimination and calibration. Patients were stratified into risk groups on the basis of the nomogram-predicted overall survival probability. The efficacy of F-OX within each risk subgroup was assessed using the log rank test and Cox regression analysis weighted by inverse propensity score.

RESULTS

Some 1464 patients were included. The nomogram showed better discrimination than the seventh AJCC staging classification (concordance index 0·72 versus 0·68 respectively; P = 0·008) and accurate calibration. F-OX was not associated with improved survival in patients in the low-risk group, whereas it reduced the risk of death by over 20 per cent in the intermediate- and high-risk groups (P = 0·036 and P < 0·001 respectively) (P for interaction = 0·014).

CONCLUSION

A nomogram can aid in individualized decision-making regarding the administration of F-OX after gastrectomy for cancer.

Surgical Considerations in the Management of Gastric Adenocarcinoma

Since Theodor Billroth and César Roux perfected the methods of postgastrectomy reconstruction in as early as the late nineteenth century, surgical management of gastric cancer has made incremental progress. The longstanding and contentious debate on the optimal extent of lymph node dissection for gastric cancer seems to have settled in favor of D2 dissection. Pylorus-preserving distal (central) gastrectomy has emerged as a less invasive, function-preserving option for T1N0 middle-third gastric cancers. Frozen section analysis of margins seems partially helpful in this direction. Last, the role of palliative gastrectomy in patients with metastatic seems less important than initially thought.

East Versus West: Differences in Surgical Management in Asia Compared with Europe and North America

In recent decades, there has been considerable worldwide progress in the treatment of gastric cancer. Gastrectomy with a modified D2 lymphadenectomy (sparing the distal pancreas and spleen) has increasingly gained acceptance as a preferable standard surgical approach among surgeons in the East and the West. Despite growing consensus significant differences still exist in surgical techniques in clinical trials and clinical practices secondary to variations in epidemiology, clinicopathologic features, and surgical outcomes among geographic regions. In addition, Western physicians tend to prefer adjuvant chemotherapy and radiotherapy after surgery instead of using S-1 chemotherapy, as is the preference in the East.

Incidence and Prognostic Value of Metastases to "Posterior" and Para-aortic Lymph Nodes in Resectable Gastric Cancer

BACKGROUND

The purpose of this retrospective study was to evaluate the incidence and prognostic value of metastases to "posterior" (8p, 12b/p, 13) and para-aortic lymph nodes in a large cohort of Western patients submitted to D2 plus lymphadenectomy.

METHODS

Removal of "posterior" nodes was performed in 743 patients, and para-aortic lymphadenectomy in a subgroup of 390 patients. After lymph node mapping and retrieval on the fresh specimen, a median number of 41 total lymph nodes were analyzed. The median follow-up period was 37 months for the entire series and 68 months for survivors.

RESULTS

Of 743 included patients, 23 (3.1%) had metastases in station 8p, 12 (1.6%) in station 12b/p, and 19 (2.6%) in station 13. On the whole, 47 of 743 patients (6.3%) had positive "posterior" nodes. Para-aortic metastases were present in 42 of 390 patients (10.8%). Metastases to "posterior" stations were significantly related to depth of invasion, number of positive nodes, and surgical radicality. Distal tumors showed higher trend to metastasize to "posterior" nodes than upper third, whereas for para-aortic metastases it was the reverse. 5-year survival in patients with positivity to "posterior" nodes was 17%, with no significant difference according to 8p, 12b/p, and 13 stations; long-term outcome was overlapping to pN3b stage. 5-year survival in para-aortic positive cases was 11%, and a trend to better outcome was observed in proximal tumors.

CONCLUSIONS

Although metastases to "posterior" and para-aortic nodes are expression of an advanced nodal stage, not negligible survival rates are observed in subgroups of patients.

Lymphadenectomy with Optimum of 29 Lymph Nodes Retrieved Associated with Improved Survival in Advanced Gastric Cancer: A 25,000-Patient International Database Study

BACKGROUND

Gastric adenocarcinoma is an aggressive disease with frequent lymph node (LN) metastases for which lymphadenectomy results in a survival benefit. In the US, the National Comprehensive Cancer Network guidelines recommend D2 lymphadenectomy or a minimum of 15 LNs retrieved. However, retrieval of only 15 LNs is considered by most international guidelines as inadequate. We sought to evaluate the survival benefits associated with a more complete lymphadenectomy.

STUDY DESIGN

An international database was constructed by combining gastric cancer cases from the Surveillance, Epidemiology, and End Results program database (n = 13,932) and the Yonsei University Gastric Cancer database (n = 11,358) (total n = 25,289). Kaplan-Meier survival analysis was performed along with Joinpoint analysis to obtain the optimal number of LNs to retrieve based on survival. Prognostic significance of number of nodes retrieved was then confirmed with univariate and multivariate analyses.

RESULTS

Analysis for both mean and median survival yielded 29 LNs removed as the Joinpoint. This was confirmed with multivariate analysis, where 15 retrieved LNs cutoff fell out of the model and 29 retrieved LNs remained intact, with a hazard ratio of 0.799 (95% CI 0.759 to 0.842; p < 0.001). Stage-stratified Kaplan-Meier analysis for a cutoff point of 29 LNs also demonstrated a statistically significant improvement in survival.

CONCLUSIONS

Joinpoint analysis has allowed for the creation of a model demonstrating the point at which additional dissection would not provide additional benefit. This large international dataset analysis demonstrates that the maximal survival advantage is seen by performing a lymphadenectomy with a minimum of 29 LNs retrieved.

The Asian Perspective on the Surgical and Adjuvant Management of Esophagogastric Cancer

In East Asia, D2 dissection has been routine surgical procedure for curable advanced gastric cancer. More extended surgery than D2 is reserved for borderline resectable disease with extended nodal metastasis. The addition of radiation therapy to adjuvant chemotherapy failed to improve the outcome after D2 dissection. Because many patients are diagnosed in East Asia with early-stage disease, postoperative adjuvant chemotherapy is preferred, and S-1 monotherapy or capecitabine-oxaliplatin is standard care. Neoadjuvant chemotherapy may be preferred for stage III tumors; for borderline resectable tumors, preoperative chemotherapy is under study given the limitations of postoperative adjuvant chemotherapy in high-risk patients.

Beyond precision surgery: Molecularly motivated precision care for gastric cancer

Gastric cancer is one of the leading causes of cancer-related deaths worldwide. Despite the high disease prevalence, gastric cancer research has not gained much attention. Recently, genome-scale technology has made it possible to explore the characteristics of gastric cancer at the molecular level. Accordingly, gastric cancer can be classified into molecular subtypes that convey more detailed information of tumor than histopathological characteristics, and these subtypes are associated with clinical outcomes. Furthermore, this molecular knowledge helps to identify new actionable targets and develop novel therapeutic strategies. To advance the concept of precision patient care in the clinic, patient-derived xenograft (PDX) models have recently been developed. PDX models not only represent histology and genomic features, but also predict responsiveness to investigational drugs in patient tumors. Molecularly curated PDX cohorts will be instrumental in hypothesis generation, biomarker discovery, and drug screening and testing in proof-of-concept preclinical trials for precision therapy. In the era of precision medicine, molecularly tailored therapeutic strategies should be individualized for cancer patients. To improve the overall clinical outcome, a multimodal approach is indispensable for advanced cancer patients. Careful, oncological principle-based surgery, combined with a molecularly guided multidisciplinary approach, will open new horizons in surgical oncology.

A High Lymph Node Yield is Associated with Prolonged Survival in Elderly Patients Undergoing Curative Gastrectomy for Cancer: A Dutch Population-Based Cohort Study

Purpose

The aim of this study was to evaluate the influence of lymph node yield (LNY) on postoperative mortality and overall survival in elderly patients with gastric cancer.

Methods

This population-based study included data from The Netherlands Cancer Registry of patients who underwent curative gastrectomy for adenocarcinoma between 2006 and 2014. Patients were divided into two groups based on age (<75 years, young; ≥75 years, elderly). LNY was analyzed as both a categorical variable (low, <15 nodes; intermediate, 15–25 nodes; high, >25 nodes), and a discrete variable. Multivariable analysis was used to evaluate the influence of LNY on 30- and 90-day mortality, as well as overall survival.

Results

A total of 3764 patients were included in the study; 2387 (63%) were classified as ‘young’, and 1377 (37%) were classified as ‘elderly’. The median LNY was 14 in the young group, compared with 11 in the elderly group (p < 0.001). In the elderly group, 851 (62%) patients had a low LNY, 333 (24%) had an intermediate LNY, and 174 (13%) had a high LNY. Multivariable analysis demonstrated that in the elderly patients, a higher LNY was associated with a prolonged overall survival (low: reference; intermediate: hazard ratio [HR] 0.74, 95% confidence interval [CI] 0.62–0.88, p < 0.001; high: HR 0.59, 95% CI 0.45–0.78, p < 0.001), but not with 30-day (p = 0.940) and 90-day mortality (p = 0.573). For young patients, these results were comparable.

Conclusion

In both young and elderly patients, a high LNY is associated with prolonged survival but not with an increase in postoperative mortality. Therefore, an extensive lymphadenectomy is the preferred strategy for all patients during gastrectomy in order to provide an optimal oncological result.

Tumor Size Is a Critical Factor in Adjuvant Chemotherapy for T3-4aN0M0 Gastric Cancer Patients after D2 Gastrectomy

Aim. To investigate whether tumor size is a reasonable indication for adjuvant chemotherapy for T_3-4aN0M0 gastric cancer patients after D2 gastrectomy. Method. We performed a retrospective study of 269 patients with a histological diagnosis of T_3-4aN0M0 stage gastric cancer who underwent D2 radical surgery at the Sun Yat-sen University Cancer Center or the Sixth Affiliated Hospital of Sun Yat-sen University between January 2006 and December 2010. The follow-up lasted until June of 2015. Chi-square tests and Kaplan-Meier methods were employed to compare the clinicopathological variables and prognoses. Result. For this group of patients, univariate analyses revealed that tumor size (p < 0.001), pathological T stage (p < 0.001), and tumor location (p = 0.025) were significant prognostic factors. Adjuvant chemotherapy did not exhibit prognostic benefits. For patients with tumors larger than 5 cm, univariate analysis revealed that tumor location (p = 0.007), Borrmann type (p = 0.039), postoperative chemotherapy (p = 0.003), and pathological T stage (p < 0.001) were significant prognostic factors. Multivariate analysis revealed that postoperative chemotherapy and pathological T stage were independent prognostic factors. Conclusion. Our results imply that tumor size should be a critical factor in the decision to utilize adjuvant chemotherapy for T_3-4aN0M0 gastric cancer patients after D2 gastrectomy. Additional randomized controlled trials are required before this conclusion can be considered definitive.

Differences in the multimodal treatment of gastric cancer: East versus west

There has been a great deal of interest about varying treatment paradigms of gastric cancer in Eastern and Western countries. Differences in tumor biology, screening initiatives, surgical approach, extent of lymphadenectomy, and neoadjuvant versus adjuvant chemotherapy regimens have been studied and documented in the literature. The purpose of this review is to give an updated report on the current status and management differences in the treatment of gastric cancer between Eastern and Western countries.

Prognostic value of diffuse versus intestinal histotype in patients with gastric cancer: a systematic review and meta-analysis

BACKGROUND

There are two distinct types of gastric carcinoma (GC), intestinal, more frequently sporadic and linked to environmental factors, and diffuse (undifferentiated) that is highly metastatic and characterized by rapid disease progression and a poor prognosis. However, there are many conflicting data in the literature concerning the association between histology and prognosis in GC. This meta-analysis was performed to provide demonstration if histology according to Lauren classification is associated with different prognosis in patients with GC.

METHODS

We searched PubMed, the Cochrane Library, SCOPUS, Web of Science, CINAHL, and EMBASE for all eligible studies. The combined hazard ratios (HRs) and their corresponding 95% confidence intervals (CIs) in terms of overall survival (OS) were evaluated.

RESULTS

A total of 73 published studies including 61,468 patients with GC were included in this meta-analysis. Our analysis indicates that GC patients with diffuse-type histology have a worst prognosis than those with intestinal subgroup in all studies (HR 1.23; 95% CI, 1.17-1.29; P<0.0001), in both loco-regional confined (HR 1.21; 95% CI, 1.12-1.30; P<0.0001) and advanced disease (HR 1.25; 95% CI, 1.046-1.50; P=0.014), in Asiatic (HR 1.2; 95% CI, 1.14-1.27; P<0.0001) and Western patients (HR 1.3; 95% CI, 1.19-1.41; P<0.0001), and in those not exposed (HR 1.15; 95% CI, 1.07-1.24; P<0.0001) or exposed (HR 1.27; 95% CI, 1.17-1.37; P<0.0001) to (neo)adjuvant therapy.

CONCLUSIONS

Our results indicated that histology might be a useful prognostic marker for both early and advanced GC patients, with intestinal-type associated with a better outcome. This information could be used for stratification purpose in future clinical trials.

Lymphadenectomy in elderly/high risk patients: should it be different?

The global aging of population will lead a greater number of elderly patients to undergo surgical procedure in a near future. Concerning gastric cancer, the impact of lymphadenectomy on survival has been demonstrated in RCTs, and extended lymphadenectomy is now considered as gold standard of treatment in non-early tumors. However, the role of age as a prognostic factor and the benefit of extended surgery in elderly/high-risk patients are not clearly defined yet. From our revision of literature, it seems that surgery for gastric cancer may have a further tailorization, considering not only the stage of disease, but also patients' age and comorbidities.

Lymphadenectomy: state of the art

The extent of lymphadenectomy in gastric cancer (GC) surgery has been for long time a matter of debate. Randomized trials performed in the West reported worse results of D2 dissection, in terms of postoperative complications and long-term survival benefit, than Eastern series and observational studies from specialized Western centers. However, long-term re-evaluation of such trials and in depth-analysis of other experiences demonstrated the potential benefit of D2 in reducing the probability of cancer-related death and the safety of this procedure when avoiding unnecessary spleno-pancreatectomy and in centers with ad adequate surgical volume. Nowadays, the D2 is considered the standard treatment in most guidelines all over the world. More limited procedures (D1, D1 plus) may be adequate in selected cases, and more extended dissections (D2 plus) could be indicated in advanced forms with high risk of metastases to distant nodes, but in specialized centers or in the setting of clinical studies. The integration with neoadjuvant therapies and multimodality approach could offer a chance of cure in groups of patients with poor results when approached with standard treatment.

Does a Higher Cutoff Value of Lymph Node Retrieval Substantially Improve Survival in Patients With Advanced Gastric Cancer?-Time to Embrace a New Digit

BACKGROUND

The present study assessed the impact of the retrieval of >25 lymph nodes (LNs) on the survival outcome of patients with advanced gastric cancer after curative-intent gastrectomy.

PATIENTS AND METHODS

A total of 5,386 patients who had undergone curative gastrectomy for gastric cancer from 1994 to 2011 were enrolled. The clinicopathological parameters and overall survival (OS) were analyzed according to the number of LNs examined (≤15, n = 916; 16-25, n = 1,458; and >25, n = 3,012).

RESULTS

The percentage of patients with >25 LNs retrieved increased from 1994 to 2011. Patients in the LN >25 group were more likely to have undergone total gastrectomy and to have a larger tumor size, poorer tumor differentiation, and advanced T and N stages. Hospital mortality among the LN ≤15, LN 16-25, and LN >25 groups was 6.1%, 2.7%, and 1.7%, respectively (p < .0001). The LN >25 group consistently exhibited the most favorable OS, in particular, with stage II disease (p = .011) when OS was stratified according to tumor stage. Similarly, the LN >25 group had significantly better OS in all nodal stages (from N1 to N3b). The discrimination power of the lymph node ratio (LNR) for the LN ≤15, LN 16-25, and LN >25 groups was 483, 766, and 1,560, respectively. Multivariate analysis demonstrated that the LNR was the most important prognostic factor in the LN >25 group.

CONCLUSION

Retrieving more than 25 lymph nodes during curative-intent gastrectomy substantially improved survival and survival stratification of advanced gastric cancer without compromising patient safety. The Oncologist 2017;22:97-106Implications for Practice: D2 lymph node (LN) dissection is currently the standard of surgical management of gastric cancer, which is rarely audited by a third party. The present study, one of the largest surgical series worldwide, has shown that the traditionally recognized retrieval of ≥16 LNs during curative-intent gastrectomy might not be adequate in regions in which locally advanced gastric cancers predominate. The presented data show that retrieval of >25 LNs, which more greatly mimics D2 dissection, improves long-term outcomes and survival stratification without compromising patient safety.

Extent of lymphadenectomy has no impact on postoperative complications after gastric cancer surgery in Sweden

Objective

Curative gastric cancer surgery entails removal of the primary tumor with adequate margins including regional lymph nodes. European randomized controlled trials with recruitment in the 1990’s reported increased morbidity and mortality for D2 compared to D1. Here, we examined the extent of lymphadenectomy during gastric cancer surgery and the associated risk for postoperative complications and mortality using the strengths of a population-based study.

Methods

A prospective nationwide study conducted within the National Register of Esophageal and Gastric Cancer. All patients in Sweden from 2006 to 2013 who underwent gastric cancer resections with curative intent were included. Patients were categorized into D0, D1, or D1+/D2, and analyzed regarding postoperative morbidity and mortality using multivariable logistic regression.

Results

In total, 349 (31.7%) patients had a D0, 494 (44.9%) D1, and 258 (23.4%) D1+/D2 lymphadenectomy. The 30-d postoperative complication rates were 25.5%, 25.1% and 32.2% (D0, D1 and D1+/D2, respectively), and 90-d mortality rates were 8.3%, 4.3% and 5.8%. After adjustment for confounders, in multivariable analysis, there were no significant differences in risk for postoperative complications between the lymphadenectomy groups. For 90-d mortality, there was a lower risk for D1 vs. D0.

Conclusions

The majority of gastric cancer resections in Sweden have included only a limited lymphadenectomy (D0 and D1). More extensive lymphadenectomy (D1+/D2) seemed to have no impact on postoperative morbidity or mortality.

Postgastrectomy follow-up in the West: evidence base, guidelines, and daily practice

Follow-up after gastrectomy for gastric cancer has several purposes, including management of side effects of surgery, oncological recurrence surveillance, psychological support, and data collection for research. How follow-up after gastrectomy, and especially recurrence surveillance, is performed differs immensely between different Western countries, despite guidelines from Western oncological organizations quite unanimously advocating symptom-driven surveillance, without scheduled cross-sectional imaging, endoscopies, or analysis of tumor markers. Given a complete lack of randomized data, the available body of observational data does not support intensive routine surveillance for recurrent disease. Moreover, studies of other cancers have shown a negative emotional impact of routine surveillance. There is an apparent need for randomized controlled trials to address the issue of optimized strategies for postgastrectomy recurrence surveillance.

Management of postoperative complications of lymphadenectomy

Gastric cancer remains a disease with poor prognosis, mainly due to its late diagnosis. Surgery remains as the only treatment with curative intent, where the goal is radical resection with free-margin gastrectomy and extended lymphadenectomy. Over the last two decades there has been an improvement on postoperative outcomes. However, complications rate is still not negligible even in high volume specialized centers and are directly related mainly to the type of gastric resection: total or subtotal, combined with adjacent organs resection and the extension of lymphadenectomy (D1, D2 and D3). The aim of this study is to analyze the complications specific-related to lymphadenectomy in gastric cancer surgery.

Report from the 17th Annual Western Canadian Gastrointestinal Cancer Consensus Conference; Edmonton, Alberta; 11-12 September 2015

The 17th annual Western Canadian Gastrointestinal Cancer Consensus Conference (wcgccc) was held in Edmonton, Alberta, 11-12 September 2015. The wcgccc is an interactive multidisciplinary conference attended by health care professionals from across Western Canada (British Columbia, Alberta, Saskatchewan, and Manitoba) who are involved in the care of patients with gastrointestinal cancer. Surgical, medical, and radiation oncologists; pathologists; radiologists; and allied health care professionals participated in presentation and discussion sessions for the purposes of developing the recommendations presented here. This consensus statement addresses current issues in the management of gastric cancer.

Surgical and Survival Outcome Following Truly Palliative Gastrectomy in Patients with Incurable Gastric Cancer

BACKGROUND AND OBJECTIVES

Gastrectomy is sometimes performed even in patients with incurable factors, particularly when they have urgent symptoms. The aim of this study was to clarify the clinicopathological characteristics of patients undergoing palliative gastrectomy and to identify prognostic factors.

METHODS

This study included consecutive 137 gastric cancer patients with urgent symptoms who underwent gastrectomy with macroscopic residual tumor at Shizuoka Cancer Center. Clinicopathological characteristics and surgical outcomes were investigated. In addition, we used the Cox proportional hazards model to identify independent prognostic factors.

RESULTS

Of 137 patients, urgent symptoms were bleeding in 58 patients and stenosis in 112 patients. Postoperative complications were observed in 58 patients (42 %). Chemotherapy was given after surgery in 94 patients (70 %). Median survival time for all patients was 9.9 months, and was longer in patients receiving chemotherapy (11.1 months) than in those not receiving chemotherapy (6.8 months; p = 0.002). Multivariate analysis identified macroscopic type (hazard ratio, 0.471; 95 % confidence interval, 0.364-0.927) as an independent prognostic factor.

CONCLUSIONS

The postoperative complication rate was high and survival outcome was poor in patients undergoing palliative gastrectomy. Postoperative chemotherapy may carry a better survival outcome, so we should try to give chemotherapy after palliative gastrectomy.

Historical assumptions of lymphadenectomy

The role of lymphadenectomy for the treatment of gastric cancer is still very much open to debate. Consequently, Japanese, European and American surgeons perform different typologies of lymphadenectomy because of the absence of randomized clinical trials confirming the superiority of extended lymphadenectomy over less invasive surgery. In Japan, D2 lymphadenectomy has been considered as the gold standard for advanced gastric carcinoma for many years. Although numerous European studies have been conducted in an attempt to find differences between D1 and D2 lymphadenectomy, none has succeeded to date. The decision to wait for results attesting to the fact that D2 guarantees a better outcome than D1 resulted in a long delay in the implementation of D2 as the gold standard treatment in Europe. In the U.S., the study by Macdonald et al. established D1 lymphadenectomy followed by chemoradiotherapy as the treatment of choice for advanced cancer, whereas D2 is officially indicated as the gold standard in the most recent European guidelines [the Italian Research Group for Gastric Cancer (GIRGC), German, British, ESSO]. Interestingly, European guidelines for lymphadenectomy are not based on evidence-based medicine but rather on the experience of the most important centers involved in the treatment of gastric cancer.

Treatment of Gastric Cancer With Paraaortic Lymph Node Metastasis

Patients with gastric cancer and paraaortic lymph node (PAN) metastasis suffered poor prognosis. The median survival time of the patients who received palliative chemotherapy was only about 12.8 months. However, the standard treatment strategy for patients with gastric cancer and PAN metastasis was controversial. This study aimed to evaluate the survival benefit of conversion chemotherapy followed by surgery in patients with gastric cancer and radiologically suspicious PAN metastasis compared with palliative chemotherapy alone. Twenty-four patients (19 males and 5 females) between January 1, 2008 and December 31, 2013 were analyzed. Fifteen patients received conversion chemotherapy followed by gastrectomy with D2 lymphadenectomy, and 9 received palliative chemotherapy. The median follow-up was 16.5 months (range: 3–50 months). The estimated median overall survival (OS) of patients who underwent the operation was longer than those who received palliative chemotherapy (44.0 versus 13.0 months; P = 0.007). Cox proportion hazard analysis indicated that surgery was a good prognostic factor for prolonged survival compared with that of palliative chemotherapy (hazard ratio: 0.211; 95% confidence interval, 0.061–0.732; P = 0.014). Moreover, the 1-year OS rate of surgical patients whose PAN shrank to &lt;1 cm was better than those who received palliative chemotherapy (87.5 versus 55.6%; log-rank P = 0.008). In conclusion, patients with gastric cancer and radiologically suspicious PAN metastasis obtained a survival benefit from conversion chemotherapy followed by gastrectomy plus D2 lymphadenectomy.

Extended lymphadenectomy in elderly and/or highly co-morbid gastric cancer patients: A retrospective multicenter study

BACKGROUND

Gastrectomy with extended lymphadenectomy is considered the gold standard treatment for advanced gastric cancer, with no age- or comorbidity-related limitations. We evaluated the safety and efficacy of curative gastrectomy with extended nodal dissection, verifying survival in elderly and highly co-morbid patients.

METHODS

In a retrospective multicenter study, we examined 1322 non-metastatic gastric-cancer patients that underwent curative gastrectomy with D2 versus D1 lymphadenectomy from January 2000 to December 2009. Postoperative complications, overall survival (OS), and disease-specific survival (DSS) according to age and the Charlson Comorbidity Score were analyzed in relation to the extent of lymphadenectomy.

RESULTS

Postoperative morbidity was 30.4%. Complications were more frequent in highly co-morbid elderly patients, and, although general morbidity rates after D2 and D1 lymphadenectomy were similar (29.9% and 33.2%, respectively), they increased following D2 in highly co-morbid elderly patients (39.6%). D2-lymphadenectomy significantly improved 5-year OS and DSS (48.0% vs. 37.6% in D1, p < 0.001 and 72.6% vs. 58.1% in D1, p < 0.001, respectively) in all patients. In elderly patients, this benefit was present only in 5-year DSS. D2 nodal dissection induced better 5-year OS and DSS rates in elderly patients with positive nodes (29.7% vs. 21.2% in D1, p = 0.008 and 47.5% vs. 30.6% in D1, p = 0.001, respectively), although it was present only in DSS when highly co-morbid elderly patients were considered.

CONCLUSION

Extended lymphadenectomy confirmed better survival rates in gastric cancer patients. Due to high postoperative complication rate and no significant improvement of the OS, D1 lymphadenectomy should be considered in elderly and/or highly co-morbid gastric cancer patients.

Tumor MICA status predicts the efficacy of immunotherapy with cytokine-induced killer cells for patients with gastric cancer

In this study, we determine the relationship between the expression of major histocompatibility complex class I chain-related gene A (MICA) in gastric cancer tumors after D2 gastrectomy and the clinical outcome of a CIK-containing adjuvant therapy. Ninety-five consecutive patients with gastric cancer after D2 gastrectomy who received adjuvant chemotherapy combined with CIK cell therapy were enrolled. The MICA expression of their tumors was determined by immunohistochemistry (IHC). High expression of MICA protein was documented by IHC in 38 of 95 tumor samples (40.0 %). The MICA status was significantly associated with the age and stage, p = 0.008 and 0.023, respectively. Analysis of NKG2D on in vitro expanded CIK cells showed that the percentages of NKG2D+ in CD3+/CD56+, CD3-/CD56+, and CD3+/CD8+ cells populations were 97.2 ± 1.4, 97.9 ± 1.8, and 95.6 ± 2.1 %, respectively. For patient with high MICA-expressing tumors, the median DFS and OS were longer than for the patients with tumors with low expression of MICA; 46.0 versus 41.0 months (p = 0.027), and 48.0 versus 42.0 months (p = 0.031), respectively. In a multivariate analysis, stage and MICA expression were independent prognostic factors for DFS and OS. Our findings show that adjuvant chemotherapy plus CIK therapy treatment is a promising modality for treating gastric cancer patients after D2 gastrectomy. Especially, those who have tumors with high expression of MICA were more likely to benefit from such a treatment strategy. Subsequent studies in clinical trial cohorts will be required to confirm the clinical utility of these markers.

Advances in Laparoscopic and Robotic Gastrectomy for Gastric Cancer

Robot-assisted gastrectomy has been reported to be a safe alternative to both conventional laparoscopy and the open approach for treating early gastric carcinoma. Currently, there are a limited number of published reports on this technique in the literature. We assessed the current status of robotic and laparoscopic surgery in the treatment of gastric cancer and compared the operative outcomes, learning curves, and oncological outcome of the two approaches. Robotic gastrectomy offers benefits that include increased ease of performing D2 lymph node dissection and reduced blood loss compared with laparoscopic gastrectomy. However, the operative time is longer, and robotic gastrectomy is more costly for the patients. Regarding to the operative and oncological outcomes, there appears to be no significant differences between laparoscopic and robotic gastrectomies after the surgeon overcomes the associated learning curves. Sharing the available knowledge regarding laparoscopic and robotic gastrectomies could shorten these learning curves. For elder patients, minimally invasive surgery that decreases the postoperative recovery time should be considered the preferred treatment. Prospective randomized studies are required to compare the surgical and oncological outcomes among laparoscopic, robotic, and open surgeries for both early and advanced gastric cancer.

Metastasis-associated protein is a predictive biomarker for metastasis and recurrence in gastric cancer

The metastasis-associated (MTA) gene family is a critical component of the nucleosome remodeling and histone deacetylase complex, and plays an important role in metastatic processes. We systematically evaluated dysregulation of the MTA family to clarify their clinical significance in gastric cancer (GC). One hundred and forty-five patients who underwent surgery for GC were evaluated. We analyzed the expression levels of the MTA family (MTA1, 2 and 3) by qPCR in GC tissue, and the MTA1 protein expression in primary cancer and matched normal mucosa (NM) was measured using immunohistochemical analysis. The expression of all the MTA family members was significantly increased in a stage-dependent manner, and elevated expression of all of the MTA family members was correlated with metastatic factors and prognosis in GC patients. Multivariate analysis revealed that MTA1 overexpression was an independent risk factor for survival. Especially, elevated expression of MTA1 was significantly correlated with recurrence, and was an independent risk factor for lymph node metastasis. Immunohistochemical analysis demonstrated that MTA1 was predominantly expressed in the nuclei of primary GC cells but was not expressed in NM and in the cancer stroma. In conclusion, quantification of MTA expression may support the accurate diagnosis of disease staging and may help predict clinical outcomes.

Potentially Curable Cancers of the Esophagus and Stomach

Gastric and gastroesophageal adenocarcinomas continue to be a major health burden globally and collectively represent the third leading cause of cancer death. Among patients with metastatic disease, most die of their cancer because of the limited number of modestly effective treatment regimens available today. The progress against these cancers has been slow compared with many other solid tumors despite many attempts. In-depth molecular profiling has also not been completed. Even when these cancers are localized, they impose considerable challenges for the patient, relatives, and treatment team alike. Localized gastric or gastroesophageal cancer is best managed with a multidisciplinary approach. This review focuses on the management of localized cancers by reviewing the current literature and explaining certain principles that help guide therapy for these patients. The future, however, will afford numerous opportunities, including exploitation of initial data from The Cancer Genome Atlas, to identify novel targets and drugs, harness the prowess of the immune system, and customize therapy for each patient.

Prognostic impact of the number of retrieved lymph nodes in patients with gastric cancer

BACKGROUND

In gastric cancer, although at least 16 lymph nodes of retrieved lymph nodes (RLNs) are recommended for nodal staging in Japanese Classification of Gastric Carcinoma and TNM classifications, we wished to clarify their appropriateness.

STUDY DESIGN

A total of 1289 consecutive gastric cancer patients, who underwent gastrectomy between 1997 and 2011, were analyzed retrospectively.

RESULTS

(i) The patients were divided into two groups using a cut-off RLN number of 16 (RLN < 16 or RLN ≥ 16). There were significant differences in the survival rates of patients in pStage II (P < 0.0001) and III (P = 0.0009), but not those of patients in pStage I (P = 0.0627) and IV (P = 0.1553). (ii) In 498 consecutive patients in pStage II and III, compared with patients in the RLN ≥ 16 group, those in the RLN < 16 group had a significantly higher incidence of older age (P = 0.0004) and positive lymph node ratio (PLNR) (P < 0.0001). Univariate and multivariate analyses showed that an RLN number of less than 16 was an independent poor prognostic factor (P < 0.0001, HR 2.48 [95% CI: 1.60-3.70]). (iii) A cut-off RLN number of 16 could cause the stage migration effect in pStage II or III patients. A cut-off RLN number of 25 or more could eliminate the prognostic effect.

CONCLUSION

The RLN number may potentially affect the prognosis and the stage migration in pStage II or III gastric cancer patients. An RLN number of 25 or more could be sufficient for nodal staging.

'Trial Exegesis': Methods for Synthesizing Clinical and Patient Reported Outcome (PRO) Data in Trials to Inform Clinical Practice. A Systematic Review

Purpose

The CONSORT extension for patient reported outcomes (PROs) aims to improve reporting, but guidance on the optimal integration with clinical data is lacking. This study examines in detail the reporting of PROs and clinical data from randomized controlled trials (RCTs) in gastro-intestinal cancer to inform design and reporting of combined PRO and clinical data from trials to improve the ‘take home’ message for clinicians to use in practice.

Materials and Methods

The case study was undertaken in gastro-intestinal cancer trials. Well-conducted RCTs reporting PROs with validated instruments were identified and categorized into those combining PRO and clinical data in a single paper, or those separating data into linked primary and supplemental papers. Qualitative methods were developed to examine reporting of the critical interpretation of the trial results (trial exegesis) in the papers in relation of the PRO and clinical outcomes and applied to each publication category. Results were used to inform recommendations for practice.

Results

From 1917 screened abstracts, 49 high quality RCTs were identified reported in 36 combined and 15 linked primary and supplemental papers. In-depth analysis of manuscript text identified three categories for understanding trial exegesis: where authors reported a “detailed”, “general”, or absent PRO rationale and integrated interpretation of clinical and PRO results. A total of 11 (30%) and 6 (16%) combined papers reported “detailed” PRO rationale and integrated interpretation of results although only 2 (14%) and 1 (7%) primary papers achieved the same standard respectively. Supplemental papers provide better information with 11 (73%) and 3 (20%) achieving “detailed” rationale and integrated interpretation of results. Supplemental papers, however, were published a median of 20 months after the primary RCT data in lower impact factor journals (median 16.8 versus 5.2).

Conclusion

It is recommended that single papers, with detailed PRO rationale and integrated PRO and clinical data are published to optimize trial exegesis. Further work to examine whether this improves the use of PRO data to inform practice is needed.

Evaluation of prognostic value and stage migration effect using positive lymph node ratio in gastric cancer

AIMS

To detect the best cut-off value of the positive lymph node ratio (PLNR) for stratifying the prognosis and analyzing its value with regard to stage migration effect using PLNR in gastric cancer.

METHODS

We retrospectively analyzed 1069 consecutive gastric cancer patients, who underwent curative gastrectomy with radical lymphadenectomy from 1997 through 2009.

RESULTS

1) The mean number of dissected lymph nodes was 42.6 in pStage I, 32.4 in pStage II and 37.1 in pStage III. The PLNR of 0.2 was proved to be the best cut-off value to stratify the prognosis of patients into two groups (P < 0.0001; PLNR <0.2 vs. PLNR ≥0.2), and patients were correctly classified into four groups: PLNR 0, PLNR 0-<0.2, PLNR 0.2-<0.4 and PLNR ≥0.4 by the Kaplan-Meier method. 2) Compared patients with the PLNR <0.2, those with the PLNR ≥0.2 had a significantly higher incidence of pT3 or greater, pN2 or greater, lymphatic invasion, vascular invasion and undifferentiated cancer. Multivariate analysis showed that the PLNR ≥0.2 was an independent prognostic factor [P < 0.0001, HR 2.77 (95% CI: 1.87-4.09)]. 2) The PLNR cut-off value of 0.2 could discriminate a stage migration effect in pN2-N3 and pStage II-III, which patients with PLNR ≥0.2 might be potentially diagnosed as a lower stage after gastrectomy.

CONCLUSION

The PLNR contributes to evaluating prognosis and stage migration effect even in a single institute and enable to identify those who need meticulous treatments and follow-up in patients with gastric cancer.

Postoperative chemoradiotherapy versus chemotherapy for R0 resected gastric cancer with D2 lymph node dissection: an up-to-date meta-analysis

BACKGROUND

This meta-analysis aims to provide more evidence on the role of postoperative chemoradiotherapy (CRT) for gastric cancer (GC) patients in Asian countries where D2 lymphadenectomy is prevalent.

METHODS

We conducted a systematic review of randomized controlled trials (RCTs), extracted data of survival and toxicities, and pooled data to evaluate the efficacy and toxicities of CRT compared with chemotherapy (CT) after D2 lymphadenectomy.

RESULTS

A total of 960 patients from four RCTs were selected. The results showed that postoperative CRT significantly reduced loco-regional recurrence rate (LRRR: RR = 0.50, 95 % CI = 0.34-0.74, P = 0.0005) and improved disease-free survival (DFS: HR = 0.73, 95 % CI = 0.60-0.89, P = 0.002). However, CRT did not affect distant metastasis rate (DMR: RR = 0.81, 95 % CI = 0.60-1.08, P = 0.15) and overall survival (OS: HR = 0.91, 95 % CI = 0.74-1.11, P = 0.34). The main grade 3-4 toxicities manifested no significant differences between the two groups.

CONCLUSIONS

Overall, CRT after D2 lymphadenectomy may reduce LRRR and prolong DFS. The role of postoperative CRT should be further investigated in the population with high risk of loco-regional recurrence.

Evaluation of rational extent lymphadenectomy for local advanced gastric cancer

Based upon studies from randomized clinical trials, the extended (D2) lymph node dissection is now recommended as a standard procedure for local advanced gastric cancer worldwide. However, the rational extent lymphadenectomy for local advanced gastric cancer has remained a topic of debate in the past decades. Due to the limitation of low metastatic rate in para-aortic nodes (PAN) in JCOG9501, the clinical benefit of D2+ para-aortic nodal dissection (PAND) for patients with stage T4 and/or stage N3 disease, which is very common in China and other countries except Japan and Korea, cannot be determined. Furthermore, the role of splenectomy for complete resection of No.10 and No.11 nodes has been controversial, and however, the final results from the randomized trial of JCOG0110 have yet to be completed. Gastric cancer with the No.14 and No.13 lymph node metastasis is defined as M1 stage in the current version of the Japanese classification. We propose that D2+No.14v and +No.13 lymphadenectomy may be an option in a potentially curative gastrectomy for tumors with apparent metastasis to the No.6 nodes or infiltrate to duodenum. The examined lymph node and extranodal metastasis are significantly associated with the survival of gastric cancer patients.

Evolution of gastric surgery techniques and outcomes

Surgical management of gastric cancer improves survival. However, for some time, surgeons have had diverse opinions about the extent of gastrectomy. Researchers have conducted many clinical studies, making slow but steady progress in determining the optimal surgical approach. The extent of lymph node dissection has been one of the major issues in surgery for gastric cancer. Many trials demonstrated that D2 dissection resulted in greater morbidity and mortality than D1 dissection. However, long-term outcomes demonstrated that D2 dissection resulted in longer survival than D1 dissection. In 2004, the Japan Clinical Oncology Group reported a pivotal trial which was performed to determine whether para-aortic lymph node dissection combined with D2 dissection was superior to D2 dissection alone and found no benefit of the additional surgery. Gastrectomy with pancreatectomy, splenectomy, and bursectomy was initially recommended as part of the D2 dissection. Now, pancreas-preserving total gastrectomy with D2 dissection is standard, and ongoing trials are addressing the role of splenectomy. Furthermore, the feasibility and safety of laparoscopic gastrectomy are well established. Survival and quality of life are increasingly recognized as the most important endpoints. In this review, we present perspectives on surgical techniques and important trials of these techniques in gastric cancer patients.

Clinical, Histological and Prognosis Correlations in Diagnosis and Treatment of Gastric Cancer

Purpose The study authors have proposed to highlight the main epidemiologic and prognostic aspects of digestive malignancies in the Dolj county population, justifying the need for permanent and detailed estimate of this phenomenon. Methods The authors of the study have proposed to outline a descriptive epidemiological panel, characteristic for the population groups at risk of developing gastric cancers and establishing clinical factors (tumor location, disease stage, type of surgery) and histological factors (histopathological type, degree of tumor differentiation) with prognostic significance having as landmark, survival rate at 5 years or disease-free survival of 5 years. Results The study was conducted on a sample of 458 patients with gastric tumors endoscopically detected, histologically confirmed and treated between 2000-2010. The epidemiological study allowed us to outline the descriptive epidemiological panel characteristic for the group of patients at risk of developing gastric cancer. Analysis of correlation between clinical parameters and histopathological parameters reached statistical threshold in multivariate statistical analysis of the localization of tumor, disease stage and histological type (p <0.0001) and the degree of differentiation of gastric carcinomas (p <0.005). Multivariate statistical analysis has detected statistically significant differences in terms of survival rate at 5 years (p> 0.001) and free interval of disease at 5 years (p> 0.001), depending on the location of the tumor, correlated with other clinical factors (disease stage, type of surgery) and histological factors (histopathological type, tumor differentiation grade), which allowed us to outline clinical, histological and prognostic groups. Conclusions Defining the clinical, histological and prognostic groups, allows an accurate assessment of patient prognosis from the time of randomization and initiation of treatment, type of surgery in advanced loco-regional, reconverted to operability, after neoadjuvant polychemotherapy being dictated by the location of the tumor (1/3 superior vs. 1 / 3 medium vs. 1/3 lower stomach).

The Results of Pancreatic Resections and Long-Term Survival for Pancreatic Ductal Adenocarcinoma: A Single-Institution Experience

OBJECTIVES

Since the early 1990s, low long-term survival rates following pancreatic surgery for pancreatic ductal adenocarcinoma have challenged us to improve treatment. In this series, we aim to show improved survival from pancreatic ductal adenocarcinoma during the era of centralized pancreatic surgery.

METHODS

Analysis of all pancreatic resections performed at Helsinki University Hospital and survival of pancreatic ductal adenocarcinoma patients during 2000-2013 were included. Post-operative complications such as fistulas, reoperations, and mortality rates were recorded. Patient and tumor characteristics were compared with survival data.

RESULTS

Of the 853 patients undergoing pancreatic surgery, 581 (68%) were pancreaticoduodenectomies, 195 (21%) distal resections, 28 (3%) total pancreatectomies, and 49 (6%) other procedures. Mortality after pancreaticoduodenectomy was 2.1%. The clinically relevant B/C fistula rate was 7% after pancreaticoduodenectomy and 13% after distal resection, and the re-operation rate was 5%. The 5- and 10-year survival rates for pancreatic ductal adenocarcinoma were 22% and 14%; for T1-2, N0 and R0 tumors, the corresponding survival rates were 49% and 31%. Carbohydrate antigen 19-9 >75 kU/L, carcinoembryonic antigen >5 µg/L, N1, lymph-node ratio >20%, R1, and lack of adjuvant therapy were independent risk factors for decreased survival.

CONCLUSION

After centralization of pancreatic surgery in southern Finland, we have managed to enable pancreatic ductal adenocarcinoma patients to survive markedly longer than in the early 1990s. Based on a 1.7-million population in our clinic, mortality rates are equal to those of other high-volume centers and long-term survival rates for pancreatic ductal adenocarcinoma have now risen to some of the highest reported.

Clinical Outcome after D1 vs D2–3 Gastrectomy for Treatment of Gastric Cancer

Background:

Clinical benefit from extended lymphadenectomy for gastric cancer remains controversial as a considerable variation exists between results of different studies.

Methods:

562 patients were treated at HUCH between 1987–2003, whereof 223 underwent gastrectomy with curative intent. Of these, 114 patients underwent subtotal/total gastrectomy with D1 (standard) lymphadenectomy and 109 patients had D2–3 (extended) lymph node dissection. The clinical outcome of these patients was analysed retrospectively.

Results:

The incidence of surgical complications was 33.0% in D2–3 and 16.8% in D1 lymphadenectomy groups (p = 0.008). Abscess was the most common complication (11.0%) among D2–3 operated patients and haemorrhage (4.4%) in D1 group. Hospital mortality was 3.7% in D2–3 and 1.8% in D1 group (p = 0.438). The only statistically significant factor influencing the rate of complications was D2–3 lymphadenectomy (OR 2.620, 95% C.I. 1.375 to 4.991). D2–3 was associated with a longer postoperative hospital stay and operation time, greater blood loss and increased need for blood transfusions compared to D1. The 5-year survival was not statistically different between lymphadenectomy groups.

Conclusion:

It is justified to perform a D2–3 gastrectomy in Europe with a acceptable postoperative mortality but with a significant morbidity. Further studies are needed to assess the value of extended lymphadenectomy in gastric cancer

The Essentials of Locoregional Control in the Treatment of Gastric Cancer

Gastric cancer is the fourth most frequent cancer in the world. For curative treatment and local control of gastric cancer, surgery is essential. The extent of the lymph node dissection is still under debate. Only one available trial showed significantly increased overall survival, whereas in all other randomised trials no significant difference could be found.

As surgery alone often is not sufficient in the curative treatment in gastric cancer, different (neo)adjuvant treatment strategies have extensively been studied. The recently published MAGIC trial showed downstaging, downsizing and an improved overall survival for patients treated with perioperative chemotherapy, compared to surgery alone (difference 13%, p = 0.009). The INT 0116 trial on the other hand, demonstrated the benefit of postoperative chemoradiotherapy compared to surgery alone for patients with a curative resection of gastric cancer. However, the quality of resections in this trial was poor, illustrating the importance of standardisation by quality control. This could be done by the Maruyama index, which quantifies the likelihood of unresected disease.

In the Netherlands, the CRITICS trial has recently been launched, which will be a quality controlled trial comparing postoperative chemoradiotherapy and chemotherapy on survival and/or locoregional control in patients who receive neoadjuvant chemotherapy followed by a D1+ gastric resection.

Potential Diagnostic, Prognostic and Therapeutic Targets of MicroRNAs in Human Gastric Cancer

Human gastric cancer (GC) is characterized by a high incidence and mortality rate, largely because it is normally not identified until a relatively advanced stage owing to a lack of early diagnostic biomarkers. Gastroscopy with biopsy is the routine method for screening, and gastrectomy is the major therapeutic strategy for GC. However, in more than 30% of GC surgical patients, cancer has progressed too far for effective medical resection. Thus, useful biomarkers for early screening or detection of GC are essential for improving patients' survival rate. MicroRNAs (miRNAs) play an important role in tumorigenesis. They contribute to gastric carcinogenesis by altering the expression of oncogenes and tumor suppressors. Because of their stability in tissues, serum/plasma and other body fluids, miRNAs have been suggested as novel tumor biomarkers with suitable clinical potential. Recently, aberrantly expressed miRNAs have been identified and tested for clinical application in the management of GC. Aberrant miRNA expression profiles determined with miRNA microarrays, quantitative reverse transcription-polymerase chain reaction and next-generation sequencing approaches could be used to establish sample specificity and to identify tumor type. Here, we provide an up-to-date summary of tissue-based GC-associated miRNAs, describing their involvement and that of their downstream targets in tumorigenic and biological processes. We examine correlations among significant clinical parameters and prognostic indicators, and discuss recurrence monitoring and therapeutic options in GC. We also review plasma/serum-based, GC-associated, circulating miRNAs and their clinical applications, focusing especially on early diagnosis. By providing insights into the mechanisms of miRNA-related tumor progression, this review will hopefully aid in the identification of novel potential therapeutic targets.

On the road to standardization of D2 lymph node dissection in a European population of patients with gastric cancer

The amount of lymph node dissection (LD) required during surgical treatment of gastric cancer surgery has been quite controversial. In the 1970s and 1980s, Japanese surgeons developed a doctrine of aggressive preventive gastric cancer surgery that was based on extended (D2) LD volumes. The West has relatively lower incidence rates of gastric cancer, and in Europe and the United States the most common LD volume was D0-1. This eventually caused a scientific conflict between the Eastern and Western schools of surgical thought: Japanese surgeons determinedly used D2 LD in surgical practice, whereas European surgeons insisted on repetitive clinical trials in the European patient population. Today, however, one can observe the results of this complex evolution of views. The D2 LD is regarded as an unambiguous standard of gastric cancer surgical treatment in specialized European centers. Such a consensus of the Eastern and Western surgical schools became possible due to the longstanding scientific and practical search for methods that would help improve the results of gastric cancer surgeries using evidence-based medicine. Today, we can claim that D2 LD could improve the prognosis in European populations of patients with gastric cancer, but only when the surgical quality of LD execution is adequate.

Evaluation of the Role of Circulating Long Non-Coding RNA H19 as a Promising Novel Biomarker in Plasma of Patients with Gastric Cancer

BACKGROUND

H19 is one of the long non-coding RNAs (LncRNA) that is related to the progression of many diseases including cancers. This work was carried out to study the level of the long non-coding RNA; H19, in plasma of patients with gastric cancer (GC) and to assess its significance in their clinical management.

METHODS

Sixty-two participants were enrolled in the present study. The first group included 32 GC patients. The second group was formed of 30 age and sex matched healthy volunteers serving as a control group. Plasma samples were used to assess H19 gene expression using real-time quantitative PCR technique.

RESULTS

H19 expression was up-regulated and closely related to TNM cancer stages in GC patients. Using Receiver Operating Characteristic (ROC) curve analysis, a cutoff level of 0.5 was set for H19 expression to diagnose GC cases achieving a sensitivity of 68.75%, specificity of 56.67%, positive predictive value (PPV) 62.86% and negative predictive value (NPV) 62.96% with an area under the curve (AUC) of 72.4%. Combined use of Carcinoembryonic Antigen (CEA) and H19 level in GC diagnosis was evaluated using ROC curve revealing improvement in performance with an area under the curve of 80.4%.

CONCLUSIONS

Up-regulation of H19 is closely associated with gastric cancer displaying progressive up-regulation in advanced stages of the disease implementing its role as a potential non-invasive diagnostic biomarker in gastric cancer and as a novel tool in gastric cancer management with better performance achieved on using both CEA and H19 simultaneously.

Mortality and Morbidity and Disease Free Survival after D1 and D2 Gastrectomy for Stomach Adenocarcinomas

BACKGROUND

A number of randomized trials addressing alternative operative and multimodality approaches to gastric cancer have characterized early postoperative morbidity and mortality rates. The aim of this study was to compare mortality and morbidity and disease free survival after D1 and D2 gastrectomy for adenocarcinomas of the stomach

MATERIALS AND METHODS

From June 2006 to January 2012, patients were selected according to information of the cancer administrator center of Ahvaz Jundishapur Medical University. The inclusion criteria were age between 20-85 years and histologically proven adenocarcinoma of the stomach without evidence of distant metastasis. Patients were excluded if they had previous or coexisting cancer or disability disease. In this research, D1 was compared to D2 gastrectomy.

RESULTS

131 patients were randomised, 49 allocated to D1 and 82 to D2 gastrectomy. The two groups were comparable for age, sex, site of tumors, and type of resection performed. The overall post-operative morbidity rate was 17.5%. Complications developed in 14.2% of patients after D1 and in 19.5% of patients after D2 gastrectomy (p=0.07). Postoperative mortality rate was 0.8% (one death); it was 2% after D1 and 0% after D2 gastrectomy. In this research disease free-survival after 3 years was 71.2 % with 63.2% after D1 and 76.8% after D2 gasterctomy.

CONCLUSIONS

This study indicates that D2 gastrectomy with pancreas preservation is not followed by significantly higher morbidity and mortality than D1 resection. Based on the results of present study, D2 resection should be recommended as the standard surgical approach for resectable gastric cancer.