Gastric cancer epidemiology and risk factors

Efficacy of SOX regimen versus XELOX regimen in concurrent chemoradiotherapy for postoperative recurrent gastric carcinoma

AIM: To evaluate the efficacy and safety of SOX regimen (S-1 + L-OHP) versus XELOX regimen (capecitabine + L-OHP) in concurrent chemoradiotherapy for postoperative recurrent gastric carcinoma.

METHODS: Sixty-six elderly patients with postoperative recurrent gastric cancer were randomly divided into two groups: an SOX group (n = 34) and a XELOX group (n = 32). The SOX group received oral S-1 (< 1.25 m², 40 mg; 1.25-1.5 m2, 50 mg; > 1.5 m², 60 mg), twice daily, d1-14; L-OHP (85 mg/m², d1); and three-dimensional conformal radiation (1.8 Gy/d, 5 d/wk and the total dose was 45 Gy). The XELOX group was treated with capecitabine (2000 mg/m², separated to twice, d1-14), plus the same regimen of radiation and L-OHP as those in the SOX group. Each cycle lasted three weeks. The efficacy and toxicity were evaluated after two cycles of treatment.

RESULTS: The efficacy and toxicity could be evaluated in 66 cases. There were no significant differences in the overall response rate (55.9% vs 46.9%), median time to progression (TTP) (6.3 mo vs 5.8 mo) or median overall survival (OS) (12.8 mo vs 12.2 mo) (P > 0.05) between the two groups. The most common toxicities in the two groups were neutropenia, thrombopenia, nausea, vomiting and diarrhea, all of which could be tolerated. However, the incidence of hand-foot syndrome was significantly higher in the SOX group than in the XELOX group (P < 0.05).

CONCLUSION: The efficacy of chemoradiotherapy based on the SOX regimen for postoperative recurrent gastric carcinoma is better than that of concurrent chemoradiotherapy based on the XELOX regimen in terms of well-tolerated toxicity.

Ethnic differences in gastric cancer genetic susceptibility: allele flips of interleukin gene

Polymorphisms in promoter regions of inflammatory cytokines have been widely studied, and potentially functional polymorphisms have been discovered. Conflicting results from meta-analyses of interleukin (IL)-1B and IL-10 polymorphisms show differences in gastric cancer susceptibilities between Caucasian and Asian populations. In particular, we note the suggestion of an allele flip in IL-1B and IL-10 gene polymorphisms. In Asian populations, the IL-1B-1464G/-511C/-31T haplotype indicates risk for gastric cancer, while the opposite haplotype, IL-1B-1464C/-511T/-31C is the risk-related allele in Caucasians. Furthermore, while IL-10-1082G/-819C/-592C is associated with gastric cancer in Asians, IL-10-1082A/-819T/-592T is linked to gastric cancer risk in Caucasians. These seemingly contradictory results may be attributed to distinct carcinogenic mechanisms underlying the different gastric cancer subtypes. The allele flip observed in IL-10 and gastric cancer appears to reflect allelic heterogeneity, similar to that observed in IL-1B. In this review, we focus on the allele flip phenomenon observed between different ethnic groups in an effort to resolve certain controversial results from recent studies on interleukin polymorphism. In addition, we re-emphasize the importance of stratifying gastric cancer subtypes based on anatomical site and Lauren classification to prevent false associations arising through dilution of true ones.

Expression of monocyte chemotactic protein-1/CCL2 in gastric cancer and its relationship with tumor hypoxia

AIM: To investigate the expression and prognostic value of CCL2 in gastric cancer, as well as its relationship with tumor hypoxia.

METHODS: Tumor tissues from 68 gastric cancer patients (GC) were analyzed, and the expression of CCL2 and hypoxia-inducible factor 1 alpha (HIF-1α) in tumor tissues was detected by immunohistochemistry. Statistical evaluations that were used included univariate log-rank tests of Kaplan-Meier curves and multivariate Cox regression model analysis.

RESULTS: CCL2 was highly expressed in 66.2% (45/68) of gastric cancer specimens. The distribution of CCL2 expression in tumor tissue was consistent with that of HIF-1α. Patients with high CCL2 expression in GC had a lower overall survival rate [50.6 mo (95%CI: 44.44-56.93) vs 64.6 mo (95%CI: 60.27-68.94), P = 0.013].

CONCLUSION: CCL2 expression correlates closely with HIF-1α expression in gastric cancer. CCL2 may be an independent prognostic marker for GC.

Abnormal FHIT protein expression may be correlated with poor prognosis in gastric cancer: a meta-analysis

Our current meta-analysis is aimed to investigate the relationships between fragile histidine triad (FHIT) protein expression and prognosis in gastric cancer patients. We searched MEDLINE (1966 ~ 2013), the Cochrane Library Database (Issue 12, 2013), EMBASE (1980 ~ 2013), CINAHL (1982 ~ 2013), Web of Science (1945 ~ 2013), and the Chinese Biomedical Database (CBM) (1982 ~ 2013) without any language restrictions. The meta-analysis was conducted using the STATA 12.0 software. Crude hazard ratios (HR) with its 95 % confidence interval (95 % CI) were calculated. Eight clinical cohort studies with a total of 1,361 gastric cancer patients were involved in our meta-analysis. Our results revealed that FHIT-negative patients exhibited a shorter overall survival (OS) time than FHIT-positive patients (HR = 1.23, 95 % CI = 1.01 ~ 1.44, P < 0.001). Ethnicity-stratified analysis demonstrated that FHIT-negative patients have significantly poorer prognosis than FHIT-positive patients among both Caucasians and Asians (all P < 0.05). In conclusion, our meta-analysis provides evidences that negative expression of FHIT protein may be correlated with poor prognosis in patients with gastric cancer. Thus, FHIT expression level may be utilized as an independent prognostic marker for gastric cancer.

The impact of esophageal reflux-induced symptoms on quality of life after gastrectomy in patients with gastric cancer

Purpose

To evaluate the prevalence of esophageal reflux-induced symptoms after gastrectomy owing to gastric cancer and assess the relationship between esophageal reflux-induced symptoms and quality of life.

Materials and Methods

From January 2012 to May 2012, 332 patients were enrolled in this cross-sectional study. The patients had a history of curative resection for gastric cancer at least 6 months previously without recurrence, other malignancy, or ongoing chemotherapy. Esophageal reflux-induced symptoms were evaluated with the GerdQ questionnaire. The quality of life was evaluated with the European Organization for Research and Treatment QLQ-C30 and STO22 questionnaires.

Results

Of the 332 patients, 275 had undergone subtotal gastrectomy and 57 had undergone total gastrectomy. The number of GerdQ(+) patients was 58 (21.1%) after subtotal gastrectomy, and 7 (12.3%) after total gastrectomy (P=0.127). GerdQ(+) patients showed significantly worse scores compared to those for GerdQ(-) patients in nearly all functional and symptom QLQ-C30 scales, with the difference in the mean score of global health status/quality of life and diarrhea symptoms being higher than in the minimal important difference. Additionally, in the QLQ STO22, GerdQ(+) patients had significantly worse scores in every symptom scale. The GerdQ score was negatively correlated with the global quality of life score (r=-0.170, P=0.002).

Conclusions

Esophageal reflux-induced symptoms may develop at a similar rate or more frequently after subtotal gastrectomy compared to that after total gastrectomy, and decrease quality of life in gastric cancer patients. To improve quality of life after gastrectomy, new strategies are required to prevent or reduce esophageal reflux.

Association between dietary antioxidant vitamins intake/blood level and risk of gastric cancer

We aimed to systematically evaluate the association between dietary intake/blood levels of antioxidant vitamins (vitamin C, vitamin E, β-carotene, and α-carotene) and gastric cancer risk. Systematic literature searches were conducted until April 2013 in Pubmed and Embase to identify relevant studies. Either a fixed- or a random-effects model was adopted to estimate overall odds ratios (ORs). Dose-response, meta-regression, subgroup, and publication bias analyses were applied. Forty articles were finally included in the present study. Higher dietary intake of vitamin C, vitamin E, β-carotene, and α-carotene was inversely associated with gastric cancer risk (for vitamin C, pooled OR=0.58, 95% CI 0.51-0.65; for vitamin E, pooled OR=0.65, 95% CI 0.57-0.74; for β-carotene, pooled OR=0.59, 95% CI 0.49-0.70; for α-carotene, pooled OR=0.69, 95% CI 0.52-0.93). Subgroup analyses suggested the effects of these antioxidant vitamins were different in gastric cancer subtypes. As indicated by dose-response analysis, a 100 mg/day increment of vitamin C intake conferred an OR of 0.78 (95% CI 0.67-0.90); a 15 mg/day increment of vitamin E intake conferred an OR of 0.79 (95% CI 0.66-0.94); and a 5 mg/day increment in β-carotene intake conferred an OR of 0.80 (95% CI 0.60-1.04). No significant association was observed between blood vitamin C, α-tocopherol, γ- tocopherol, β-carotene and α-carotene levels and gastric cancer risk. In conclusion, dietary intake of vitamin C, vitamin E, β-carotene and α-carotene was inversely associated with gastric cancer risk while no such association was observed for blood levels of these antioxidant vitamins, thus the results should be interpreted cautiously.

The use of lipid-coated nanodiamond to improve bioavailability and efficacy of sorafenib in resisting metastasis of gastric cancer

The metastasis is one of the greatest challenges for successful cancer therapy. Herein, we report a lipid-coated nanodiamond (ND) system loading water-insoluble sorafenib (SND) to improve the bioavailability and efficacy on suppression of cancer metastasis. SND was homogenous nanoassemblies with the mean diameter of 127.6 ± 12.9 nm. Compared with the drug suspension, the sorafenib concentration in gastrointestinal (GI) tract and major organs was significantly increased by SND. Moreover, the oral bioavailability of sorafenib was greatly improved 7.64-fold by SND. However, the ND in SND could not be absorbed into the mucus of GI tract or distributed into major organs after oral administration. Furthermore, the sorafenib concentration in tumor tissue was markedly improved 14.95 folds by SND, and SND demonstrated an efficient and impressive tumor growth inhibition effect in tumor xenograft models. In particular, the metastasis of gastric cancer to distant organs of liver and kidney was remarkably suppressed by SND, which was verified by the detection of macroscopic metastatic nodules, histological examination and immunofluorescence measurements. Thereby, the lipid-coated ND could be a promising drug delivery platform for improving the oral bioavailability of lipophilic drugs and treatment of cancer metastasis.

An insertion/deletion polymorphism within the proximal promoter of EGLN2 is associated with susceptibility for gastric cancer in the Chinese population

Gastric cancer (GC) is among the most common human malignancies and the second leading cause of cancer-related death worldwide. Accumulated evidence from molecular genetics indicates that an individual's genetic factors are involved in their susceptibility to GC. Hypoxia is a common feature of cancer and the hypoxia-inducible factor (HIF), a transcription factor that regulates oxygen homeostasis, plays key roles in the growth of solid tumors and regulating cellular responses to hypoxia. Prolyl hydroxylase (PHD1, also known as EGLN2) is one of the three enzymes capable of hydroxylating the alpha subunit of HIF and results in polyubiquitinylation and proteasomal degradation of HIF. A case-control study, including 415 GC patients and 830 healthy controls, was conducted to investigate the association between GC susceptibility with a 4-bp insertion/deletion polymorphism (rs10680577) in the proximal promoter of EGLN2. Logistic regression analysis showed that the heterozygote and the homozygote 4-bp del/del confer a significantly increased risk of GC after controlling for other covariates (adjusted odds ratio [OR]=1.35, 95% confidence interval [CI] 1.05-1.75, p=0.017; OR=2.19, 95% CI 1.15-4.18, p=0.009, respectively). Carriage of the 4-bp deletion allele was associated with a greatly increased risk of developing the disease (OR=1.38, 95% CI 1.12-1.70, p=0.002). Moreover, stratification analysis showed that the association was more prominent in smokers (adjusted OR=2.09, 95% CI=1.40-3.12, p for heterogeneity=0.01). Our data suggested that common genetic polymorphisms in EGLN2 may influence GC risk in the Chinese population. Considering the relative small sample size, replication in other populations with a larger sample size and further functional analysis are required for fully understanding the roles of EGLN2 polymorphisms in predisposition for GC.

Proteomic approaches in biomarker discovery: new perspectives in cancer diagnostics

Despite remarkable progress in proteomic methods, including improved detection limits and sensitivity, these methods have not yet been established in routine clinical practice. The main limitations, which prevent their integration into clinics, are high cost of equipment, the need for highly trained personnel, and last, but not least, the establishment of reliable and accurate protein biomarkers or panels of protein biomarkers for detection of neoplasms. Furthermore, the complexity and heterogeneity of most solid tumours present obstacles in the discovery of specific protein signatures, which could be used for early detection of cancers, for prediction of disease outcome, and for determining the response to specific therapies. However, cancer proteome, as the end-point of pathological processes that underlie cancer development and progression, could represent an important source for the discovery of new biomarkers and molecular targets for tailored therapies.

Study of risk factors for gastric cancer by populational databases analysis

AIM: To study the association between the incidence of gastric cancer and populational exposure to risk/protective factors through an analysis of international databases.

METHODS: Open-access global databases concerning the incidence of gastric cancer and its risk/protective factors were identified through an extensive search on the Web. As its distribution was neither normal nor symmetric, the cancer incidence of each country was categorized according to ranges of percentile distribution. The association of each risk/protective factor with exposure was measured between the extreme ranges of the incidence of gastric cancer (under the 25^th percentile and above the 75^th percentile) by the use of the Mann-Whitney test, considering a significance level of 0.05.

RESULTS: A variable amount of data omission was observed among all of the factors under study. A weak or nonexistent correlation between the incidence of gastric cancer and the study variables was shown by a visual analysis of scatterplot dispersion. In contrast, an analysis of categorized incidence revealed that the countries with the highest human development index (HDI) values had the highest rates of obesity in males and the highest consumption of alcohol, tobacco, fruits, vegetables and meat, which were associated with higher incidences of gastric cancer. There was no significant difference for the risk factors of obesity in females and fish consumption.

CONCLUSION: Higher HDI values, coupled with a higher prevalence of male obesity and a higher per capita consumption of alcohol, tobacco, fruits, vegetables and meat, are associated with a higher incidence of gastric cancer based on an analysis of populational global data.

Differential association of RANTES-403 and IL-1B-1464 polymorphisms on histological subtypes in male Korean patients with gastric cancer

The aims of this study were to elucidate the association between RANTES-403 and an increased risk of gastric cancer in Korean males and to investigate the gene-gene interaction between IL-1B and RANTES. In total, 218 male patients with gastric cancer (114 diffuse types, 97 intestinal types, and 7 mixed types) and 377 male controls were included. RANTES-403 was genotyped, and age-adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were estimated by logistic regression. A multifactor dimensionality reduction (MDR) test with three-way split interval validation confirmed by likelihood ratio and permutation analysis was carried out. A significant increase in the risk of gastric cancer for the intestinal-type group was observed for IL-1B-1464G carriers (OR = 2.535; 95% CI = 1.121-5.732; P = 0.02) as well as for those with IL-1B-1464 CG (OR = 2.342; 95% CI = 0.998-5.500; P = 0.05) or IL-1B-1464 GG (OR = 2.819; 95% CI = 1.170-6.793; P = 0.02). For the RANTES-403 genotype, there was no significant difference in the risk of gastric cancer between the overall gastric cancer and the control groups. When further stratified according to histological types, RANTES-403A carriers (OR = 1.743; 95% CI = 1.086-2.798; P = 0.021) or heterozygotes (OR = 1.791; 95% CI = 1.092-2.935; P = 0.021) showed increased risk for developing diffuse-type gastric cancer. MDR revealed a three-way locus-locus interaction between RANTES-403AA, IL-1B-1464GG, and IL-1B-511CT for diffuse-type gastric cancer in Korean males. We demonstrated that RANTES-403 was significantly associated with the risk of developing diffuse-type gastric cancer in men and found a possible gene-gene interaction between RANTES and IL-1B polymorphisms in gastric cancer carcinogenesis.

Tetraspanin CD151 expression associated with prognosis for patients with advanced gastric cancer

PURPOSE

Tetraspanin CD151 is known to be involved in cancer invasion and metastasis, and its overexpression appears to be associated with a poor prognosis for various types of cancer. However, the expression status of CD151 and its prognostic impact in advanced gastric cancer (AGC) has not yet been clarified.

METHODS

Immunohistochemistry was used to investigate the expression of CD151, c-erbB2, and c-Met in 159 cases of AGC. The clinicopathological and prognostic significance of these biomarkers were then evaluated.

RESULTS

The overexpression of CD151 was observed in a subset of advanced gastric adenocarcinomas (25.8 %), and c-erbB2 and c-Met were overexpressed in 15.1 and 35.2 % of the cohort, respectively. CD151 overexpression was more frequently observed in tumors from younger patients (P = 0.028). There were close associations between CD151 and c-erbB2 overexpression (P = 0.033) and between c-erbB2 and c-Met overexpression (P = 0.001). CD151 overexpression was closely correlated with patient' overall survival (OS; P < 0.001) and disease-free survival (DFS; P < 0.001). Furthermore, the expression rate of CD151 seemed to increase gradually according to the depth of invasion (T stage) (χ(2) test for trend; P = 0.101), N stage (P = 0.238), and pathologic stage (P = 0.153), although trends were not statistically significant. In a multivariate analysis, CD151 overexpression was an independent prognostic factor predicting worse OS (P = 0.002) and DFS (P = 0.005), along with the T and N stage.

CONCLUSIONS

CD151 was found to be an independent prognostic marker for patients with AGC.

Age, poverty, acculturation, and gastric cancer

BACKGROUND

Gastric cancer is an aggressive disease, and overall changes in incidence rates have been noted. There are conflicting data on whether young patients have worse outcomes than older patients; the roles of tumor biology and access to care are critical to answering this question. Our objectives were to explore how gastric cancer rates, receipt of care, and outcomes are affected by age, poverty, and acculturation.

METHODS

A total of 42,187 patients were identified from the 1980-2009 Surveillance, Epidemiology, and End Results registry. We compared trends in incidence rates between patients <40, 40-64, and ≥65 years using ordinary least-squares regression. Separate multivariate regression models were used to evaluate the impact of age, poverty, and acculturation on receipt of cancer-directed therapy and hazard of mortality.

RESULTS

Patients <40 years had stable incidence rates over the 3-decade period compared with decreases for patients 40-64 and ≥65 years. They are also more likely to present with aggressive, advanced disease (P < .0001 for both). On unadjusted and adjusted analyses, patients <40 years were more likely to receive cancer-directed therapies and have better survival than those ≥65 years. Residing in high poverty areas was associated with not receiving appropriate cancer-directed therapy; the adjusted hazard ratio of mortality for surgically resected patients was, however, not affected by poverty. Residing in high immigration areas was associated with a low hazard ratio (HR, 0.74; 95% confidence interval [CI], 0.7-0.79) of mortality. Foreign-born patients also had a low hazard ratio (HR, 0.87; 95% CI, 0.83-0.91) of mortality.

CONCLUSION

Although trends in incidence rates for patients <40 years remain unchanged and their disease is aggressive and advanced at presentation, they do not experience disparities in gastric cancer-directed therapies and survival after resection. For patients residing in impoverished areas or high immigration communities, operative resection and adjustment for appropriate aftercare is associated with comparable or better survival when compared with those living in low poverty or low immigration areas. Disparities remain in receipt of appropriate cancer-directed therapies, and future efforts should focus on decreasing structural variations in care and unconscious biases regarding patients from these vulnerable communities.

Natural history of malignant bone disease in gastric cancer: final results of a multicenter bone metastasis survey

BACKGROUND

Bone metastasis represents an increasing clinical problem in advanced gastric cancer (GC) as disease-related survival improves. In literature, few data on the natural history of bone disease in GC are available.

PATIENTS AND METHODS

Data on clinicopathology, skeletal outcomes, skeletal-related events (SREs), and bone-directed therapies for 208 deceased GC patients with evidence of bone metastasis were statistically analyzed.

RESULTS

Median time to bone metastasis was 8 months (CI 95%, 6.125-9.875 months) considering all included patients. Median number of SREs/patient was one. Less than half of the patients (31%) experienced at least one and only 4 and 2% experienced at least two and three events, respectively. Median times to first and second SRE were 2 and 4 months, respectively. Median survival was 6 months after bone metastasis diagnosis and 3 months after first SRE. Median survival in patients who did not experience SREs was 5 months. Among patients who received zoledronic acid before the first SRE, the median time to appearance of first SRE was significantly prolonged compared to control (7 months vs 4 months for control; P: 0.0005).

CONCLUSIONS

To our knowledge, this retrospective analysis is the largest multicenter study to demonstrate that bone metastases from GC are not so rare, are commonly aggressive and result in relatively early onset of SREs in the majority of patients. Indeed, our large study, which included 90 patients treated with ZOL, showed, for the first time in literature, a significant extension of time to first SRE and increase in the median survival time after diagnosis of bone metastasis. Taken together, these data may support the beneficial effects of ZOL in GC patients.

High level of serum AMBP is associated with poor response to paclitaxel-capecitabine chemotherapy in advanced gastric cancer patients

Gastric cancer is one of the most common human cancers and ranks the second in the global cancer-related mortality. The clinical outcome of patients with advanced gastric cancer (AGC) is markedly dependent on their response to the chemotherapy. Paclitaxel plus capecitabine, as a first-line regimen, is widely administrated in AGC patients, but more than a half of the patients have a poor response, possibly due to their resistance to the treatment. Therefore, it is important to identify potential responders to improve the efficacy of the chemotherapy. In the present study, we used an isobaric tag approach for relative and absolute quantification combined with ESI-QUAD-TOF/MS to identify potential predictive biomarkers for the chemotherapy. We found 211 serum proteins, and confirmed 17 candidates that were differentially present in the progression of disease (PD) group and the partial response (PR) group to the treatment of paclitaxel plus capecitabine. In further validation of the 17 candidates in the set of 12 PD and 12 PR AGC patients, we identified a higher level of AMBP (Alpha-1-Microglobulin/Bikunin Precursor) in the sera of PD patients than of the PR patients assayed by ELISA (9.13 ± 0.45 vs. 8.11 ± 0.26 μg/mL, p = 0.06) and by the Western blotting (relative gray value 396.4 ± 39.1 vs. 275.0 ± 34.76, p = 0.03), respectively. The receiver operating characteristics curve showed 75% sensitivity and 75% specificity of AMBP in AGC patients treated with the chemotherapy. Our data indicated that the high level of serum AMBP could predict the poor response of the AGC patients treated with the paclitaxel-capecitabine chemotherapy, which could be used as a potential biomarker to identify patients who would benefit from this chemotherapeutic regimen.

Bovine lactoferricin B induces apoptosis of human gastric cancer cell line AGS by inhibition of autophagy at a late stage

Gastric cancer is one of the most common malignant cancers, with poor prognosis and high mortality rates worldwide. Therefore, development of an effective therapeutic method without side effects is an urgent need. It has been reported that cationic antimicrobial peptides can selectively bind to negatively charged prokaryotic and cancer cell membranes and exert cytotoxicity without causing severe drug resistance. In the current study, we prepared a series of peptide fragments derived from bovine lactoferrin and evaluated their anticancer potency toward the gastric cancer cell line AGS. Cell viability assay revealed that a 25-AA peptide fragment, lactoferricin B25 (LFcinB25), exhibited the most potent anticancer capability against AGS cells. Lactoferricin B25 selectively inhibited AGS cell growth in a dose-dependent manner, exhibiting a half-maximal inhibitory concentration (IC50) value of 64 μM. Flow cytometry showed a notable increment of the sub-G1 populations of the cell cycle, indicating the induction of apoptosis by LFcinB25. Western blot analysis further revealed that upon LFcinB25 treatment for 2 to 6h, apoptosis-related caspases-3, 7, 8, 9, and poly(ADP-ribose) polymerase (PARP) were cleaved and activated, whereas autophagy-related LC3-II and beclin-1 were concomitantly increased. Thus, both apoptosis and autophagy are involved in the early stage of LFcinB25-induced cell death of AGS cells. However, upon treatment with LFcinB25 for 12 to 24h, LC3-II began to decrease, whereas cleaved beclin-1 increased in a time-dependent manner, suggesting that consecutive activation of caspases cleaved beclin-1 to inhibit autophagy, thus enhancing apoptosis at the final stage. These findings provide support for future application of LFcinB25 as a potential therapeutic agent for gastric cancer.

Minimally invasive treatment of peristomal metastases from gastric cancer at an ileostomy site by electrochemotherapy

Background

Peristomal metastases are rare, but potentially associated with relevant morbidity. Surgical resection, followed by stoma relocation, represent the gold standard in most patients. We describe electrochemotherapy (ECT), a minimally invasive method for locally-enhancing drug delivery by means of electric pulses, as an alternative approach.

Patient and methods

A 49-year-old man with advanced gastric cancer developed skin metastases around an ileostomy site. The ulcerated and oozing tumor growth impaired patient’s quality of life due to continuous trouble in fitting the ostomy appliance, its poor adherence and consequent stools spillage. ECT consisted of a 20-minute course under mild general sedation. A bleomycin bolus of 15 000 IU/m² was followed by the percutaneous application of multiple, 1.5 ms -long electric pulses by means of a needle electrode.

Results

Post ECT course was uneventful and the patient was discharged on the same day. After one week, tumor nodules were flattened and partial tumor regression was appreciable at one-month follow-up. More importantly, peristomal skin conditions significantly improved, thus allowing for an effective application of the ostomy appliance during the following moths, until patient’s death.

Conclusions

This report suggests the feasibility of ECT as a minimally invasive approach for peristomal tumors. In selected cases, ECT, by achieving a rapid tumor control, may ensure effective ostomy management and preserve patients’ quality of life.

Risk factors of postoperative pancreatic fistula in curative gastric cancer surgery

PURPOSE

Postoperative pancreatic fistula is a dreadful complication after gastric cancer surgery. The purpose of this study is to evaluate the actual incidence and risk factors of postoperative pancreatic fistula after curative gastrectomy for gastric cancer.

MATERIALS AND METHODS

A total of 900 patients who underwent gastrectomy for gastric cancer (laparoscopic gastrectomy, 594 patients; open gastrectomy 306 patients) were enrolled between January 2009 and December 2010. Clinical outcomes, including postoperative pancreatic fistula grade based on the International Study Group on Pancreatic Fistula, were investigated.

RESULTS

Overall, the postoperative pancreatic fistula rate was 3.3% (30/900) (1.5% in laparoscopic gastrectomy versus 6.9% in open gastrectomy, P<0.001). Patients who underwent D2 lymphadenectomy, total gastrectomy, splenectomy or distal pancreatectomy showed higher postoperative pancreatic fistula rates (4.7%, 13.8%, 13.6%, or 57.1%, respectively, P<0.001). Patients with postoperative pancreatic fistula had higher morbidity (46.7% versus 13.1%, P<0.001), delayed gas out (4.9 days versus 3.8 days, P<0.001), belated diet start (5.8 days versus 3.5 days, P<0.001) and longer postoperative hospital stay (13.7 days versus 6.8 days, P<0.001). On the multivariate analysis, total gastrectomy (odds ratio 9.751, 95% confidence interval: 3.348 to 28.397, P<0.001), distal pancreatectomy (odds ratio 7.637, 95% confidence interval: 1.668 to 34.961, P=0.009) and open gastrectomy (odds ratio 2.934, 95% confidence interval: 1.100 to 7.826, P=0.032) were the independent risk factors of postoperative pancreatic fistula.

CONCLUSIONS

Laparoscopic gastrectomy had an advantage over open gastrectomy in terms of the lower postoperative pancreatic fistula rate. Total gastrectomy and combined resection, such as distal pancreatectomy, should be performed carefully to minimize postoperative pancreatic fistula in gastric cancer surgery.

Expression and prognostic significance of Livin in gastric cancer

Livin is one of the most important members of the inhibitor of apoptosis protein family. It is overexpressed in several types of tumors and may have prognostic significance. The present study investigated the biological role of Livin in the oncogenic behavior of gastric cancer cells, the expression of Livin in gastric cancer tissue and the relationship of its expression with various clinicopathological parameters and patient survival. Small interfering RNA blocked Livin gene expression in AGS and SNU638 human gastric cancer cell lines. The expression of Livin was investigated in gastric cancer tissues by RT-PCR, western blotting and immunohistochemistry. The associations with various clinicopathological parameters and survival were analyzed. Livin knockdown inhibited tumor cell migration, invasion and proliferation in AGS and SNU638 cells. Livin knockdown induced apoptosis by activating caspase-3, caspase-7 and PARP. Livin knockdown induced cell cycle arrest by a decrease in cyclin D1, cyclin-dependent kinase 4 and 6 and an increase in expression of p21 and p27. The ERK1/2 and JNK signaling pathways were inhibited by Livin knockdown. Livin expression was upregulated in gastric cancer tissues at the mRNA and protein levels. However, no significant correlation was found between Livin expression and various clinicopathological parameters including survival. In conclusion, Livin expression may be important in the alteration of invasive and oncogenic phenotypes of gastric cancer cells. The prognostic relevance of Livin remains unclear.

Prognostic value of epidermal growth factor receptor in patients with gastric cancer: a meta-analysis

BACKGROUND

The epidermal growth factor receptor (EGFR) plays important roles in the development of gastric cancer. This study aims to analyze the prognostic value of EGFR in patients with gastric cancer.

METHODS

A meta-analysis is performed by searching Cochrane Library, PubMed, EMBASE and Science Direct databases from Jan 1970 to May 2013. Data are extracted from studies evaluating the survival of gastric cancer patients with either positive or negative EGFR expression. Pooled hazard ratios (HRs) and 95% confidence intervals (CIs) are calculated.

RESULTS

Totally 1600 cases of gastric cancer patients from five studies are subjected to final analysis. The HR of post-operational survival of patients with positive EGFR expression is 1.16 (95% CI: 0.94-1.43) as compared with those with negative expression, indicating that positive EGFR expression does not significantly predict the poor survival of gastric cancer.

CONCLUSIONS

EGFR expression is not an independent predictor for the survival of gastric cancer patients.

[Prevalence of gastric polypoid lesions at an endoscopic facility]

BACKGROUND

The prevalence of gastric polyps is unknown in Hungary.

AIM

The aim of the authors was to assess the prevalence of polypoid lesions of the stomach in the endoscopic centre of the 2nd Department of Medicine, Semmelweis University.

METHODS

Results of upper gastrointestinal endoscopies carried out between March 2010 and June 2011 were analysed.

RESULTS

193 cases with polyps were diagnosed in 4174 endoscopies (4.62%). Hyperplastic polyps, fundic gland polyps and malignant lesion were detected in 33.67%, 31.09% and 2.07% of the cases, respectively. Proton pump inhibitor use was more frequent among patients diagnosed with fundus gland polyps (p = 0.007), while hyperplastic polyps were diagnosed more frequently in patients with chronic gastritis (p = 0.032).

CONCLUSIONS

The frequency of gastric polyps was higher than expected from data published in the literature. Long-term proton pump-inhibitor use and chronic gastritis were associated with fundus gland and hyperplastic polyps, respectively.

Gastrointestinal lymphomas: Morphology, immunophenotype and molecular features

Primary gastrointestinal lymphoma comprises 10-15% of all non-Hodgkin lymphomas and encompasses 30-40% of the total extranodal lymphomas. Approximately 60-75% of cases occur in the stomach, and then the small bowel, ileum, cecum, colon and rectum. Lymphoid neoplasms may consist of mature B, T and less commonly extranodal NK/T cells. Of these, the two most frequently encountered histologic subtypes are extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma), where Helicobacter pylori infection is implicated in a number of cases, and diffuse large B cell lymphoma. Several B cell lymphomas are associated with chromosomal aberrations. Enteropathy-associated T cell lymphoma, type I in particular, usually arises in a background of celiac disease. T cell gene rearrangement confirms clonality. NK/T cell neoplasms are invariably associated with Epstein-Barr virus infection and are often aggressive; thus, differentiation from a benign NK-cell enteropathy is paramount. Although incidence of other hematopoietic malignancies in the gastrointestinal tract such as plasma cell myeloma associated with amyloidosis, plasmablastic lymphoma, Hodgkin disease, histiocytic sarcoma and mast cell sarcoma is extremely rare, these entities have been documented, with the latter two demonstrating aggressive clinical behavior. Endoscopic ultrasonography is an important adjunct in disease staging and follow-up. Conservative antibiotic treatment of stage I MALT lymphomas with associated Helicobacter pylori infection achieves good clinical outcome with high remission rate. Chemotherapy, radiation and rarely surgery are reserved for advanced diseases or cases resistant to conservative therapy and those not associated with Helicobacter pylori infection.