Improved survival in patients with lymph node-positive gastric cancer who received preoperative radiation: an analysis of the Surveillance, Epidemiology, and End Results database

Survival benefit after neoadjuvant or adjuvant radiotherapy for stage II–III gastroesophageal junction adenocarcinoma: A large population-based cohort study

Objective

The standard treatment for stage II–III gastroesophageal junction adenocarcinoma (GEJA) remains controversial, and the role of radiotherapy (RT) in stage II–III GEJA is unclear. Herein, we aimed to evaluate the prognosis of different RT sequences and identify potential candidates to undergo neoadjuvant RT (NART) or adjuvant RT (ART).

Materials and methods

In total, we enrolled 3,492 patients with resectable stage II–III GEJA from the Surveillance, Epidemiology, and End Results (SEER) database, subsequently assigned to three categories: T_1–2N⁺, T_3–4N⁻, and T_3–4N⁺. Survival curves were evaluated using the Kaplan–Meier method along with the log-rank test. We compared survival curves for NART, ART, and non-RT in the three categories. To further determine histological types impacting RT-associated survival, we proposed new categories by combining the tumor, node, and metastasis (TNM) stage with Lauren’s classification.

Results

ART afforded a significant survival benefit in patients with T_1–2N⁺ and T_3–4N⁺ tumors. In addition, NART conferred a survival advantage in patients with T_3–4N⁺ and T_3–4 exhibiting the intestinal type. Notably, ART and NART were both valuable in patients with T_3–4N⁺, although no significant differences between treatment regimens were noted.

Conclusions

Both NART and ART can prolong the survival of patients with stage II–III GEJA. Nevertheless, the selection of NART or ART requires a concrete analysis based on the patient’s condition.

Comparison of Four Lymph Node Staging Systems in Gastric Adenocarcinoma after Neoadjuvant Therapy – A Population-Based Study

Introduction

Neoadjuvant treatment leads in a reduction in positive lymph nodes and examined lymph nodes (ELN), which may affect assessment of lymph node staging and postoperative treatment. We aimed to compare the staging systems of lymph node ratio (LNR), the positive logarithm ratio of lymph nodes (LODDS), negative lymph nodes (NLN), and the 8th AJCC ypN stage for patients with gastric adenocarcinoma after neoadjuvant therapy.

Materials and Methods

Data was collected from the Surveillance, Epidemiology, and End Results database and 1,551 patients with gastric adenocarcinoma who underwent neoadjuvant therapy and radical surgery were enrolled. Harrell’s concordance index, the Receiver Operative Curve, the likelihood ratio test, and the Akaike information criterion were used to compare the predictive abilities of the different staging systems.

Results

Among the 1,551 patients, 689 (44.4%) had ELN < 16 and node-negative patients accounted for 395 (25.5%). When regarded as the categorical variable, LNR had better discrimination power, higher homogeneity, and better model fitness for CSS and OS compared to other stage systems, regardless of the status of ELN. When regarded as the continuos variable, LODDS outperformed others for CSS. Furthermore, the NLN staging system performed superior to others in node-negative patients.

Conclusions

LNR had a better predictive performance than ypN, LODDS and NLN staging systems regardless of the status of ELN when regarded as the categorical variable, whereas LOODS became the better predictive factor for CSS when regarded as the continuos variable. In node-negative patients, NLN might be a feasible option for evaluating prognosis. A combination of LNR and NLN should be considered as user-friendly method in the clinical prognostic assessment.

Neo-adjuvant radiation therapy provides a survival advantage in T3-T4 nodal positive gastric and gastroesophageal junction adenocarcinoma: a SEER database analysis

BACKGROUND

Due to negative results in clinical trials of postoperative chemoradiation for gastric cancer, at present, there is a tendency to move chemoradiation therapy forward in gastric and gastroesophageal junction (GEJ) adenocarcinoma. Several randomized controlled trials (RCTs) are currently recruiting subjects to investigate the effect of neo-adjuvant radiotherapy (NRT) in gastric and GEJ cancer. Large retrospective studies may be beneficial in clarifying the potential benefit of NRT, providing implications for RCTs.

METHODS

We retrieved the clinicopathological and treatment data of gastric and GEJ adenocarcinoma patients who underwent surgical resection and chemotherapy between 2004 and 2015 from Surveillance, Epidemiology, and End Results (SEER) database. We compared survival between NRT and non-NRT patients among four clinical subgroups (T_1-2N^-, T_1-2N⁺, T_3-4N^-, and T_3-4N⁺).

RESULTS

Overall, 5272 patients were identified, among which 1984 patients received NRT. After adjusting confounding variables, significantly improved survival between patients with and without NRT was only observed in T_3-4N⁺ subgroup [hazard ratio (HR) 0.79, 95% confidence interval (CI): 0.66-0.95; P = 0.01]. Besides, Kaplan-Meier plots showed significant cause-specific survival advantage of NRT in intestinal type (P <  0.001), but not in diffuse type (P = 0.11) for T_3-4N⁺ patients. In the multivariate competing risk model, NRT still showed survival advantage only in T_3-4 N⁺ patients (subdistribution HR: 0.77; 95% CI: 0.64-0.93; P = 0.006), but not in other subgroups.

CONCLUSIONS

NRT might benefit resectable gastric and GEJ cancer patients of T3-4 stages with positive lymph nodes, particularly for intestinal-type. Nevertheless, these results should be interpreted with caution, and more data from ongoing RCTs are warranted.

Impact of Lymph Nodes Examined on Survival in ypN0 Gastric Cancer Patients: a Population-Based Study

BACKGROUND

Our aim was to evaluate the prognostic value of the number of lymph nodes examined (eLNs) on survival in ypN0 gastric cancer (GC) patients, and further to define the optimal number of lymph nodes needed to be examined during radical gastrectomy of ypN0 GC patients.

METHODS

A total of 1127 ypN0 GC patients during 2004-2015 from the Surveillance, Epidemiology, and End Results (SEER) database were included. The number of eLNs cutoff points that determined the greatest actuarial survival difference was calculated by the X-tile program. Univariate and multivariate analyses were performed to assess the impact of eLNs on overall survival (OS).

RESULTS

The optimal number of eLNs thresholds was determined to be 15 for ypN0 GC patients. Kaplan-Meier analysis revealed that ypN0 GC patients with ≥ 16 eLNs had a significantly better OS than those with ≤ 15 eLNs (5-year OS; 60.8 vs 45.4%, P < 0.001). Similarly, multivariate Cox analysis revealed that ypN0 GC patients with ≥ 16 eLNs experienced a significantly lower hazard of death than those with ≤ 15 eLNs (adjusted HR; 0.73, 95% CI, 0.60-0.90, P = 0.003).

CONCLUSIONS

The number of eLNs was an independent predictor of survival for ypN0 GC patients. A minimum of 15 eLNs is recommended as the cutoff point for the evaluation of the quality of postoperative or prognostic stratification in ypN0 GC patients.

Proposal of a Nomogram for Predicting Survival in Patients with Siewert Type II Adenocarcinoma of the Esophagogastric Junction After Preoperative Radiation

Background

Preoperative radiotherapy tends to be more frequently used for patients with adenocarcinoma of the esophagogastric junction (AEG); however, the prognostic values of postoperative pathologic characteristics in these patients remain unclear. This study aimed to examine the outcomes in Siewert type II AEG patients receiving preoperative radiotherapy to identify the predictive factors for overall survival (OS).

Methods and Results

A total of 1818 AEG patients undergoing preoperative radiotherapy were reviewed. Univariate analyses showed that age, sex, histology, tumor grade, positive lymph node (PLN), lymph node ratio, and log odds of positive lymph nodes (LODDS) were significantly correlated with OS; however, only age, grade, PLN, and LODDS were identified as independent risk factors in a multivariate regression model. Subsequently, patients were randomly grouped into training and validation cohorts (1:1 ratio), and the beta coefficients of these variables in the training set were used to generate the nomogram. The composite nomogram showed improved prognostic accuracy in the training, validation, and entire cohorts compared with that of TNM stage alone.

Conclusions

In conclusion, our proposed nomogram represents a promising tool for estimating OS in Siewert type II AEG patients after preoperative radiotherapy.

Electronic supplementary material

The online version of this article (10.1245/s10434-019-07237-7) contains supplementary material, which is available to authorized users.

Central Lymph Node Metastasis in Gastric Cancer Is Predictive of Survival After Preoperative Therapy

BACKGROUND

It is unclear how preoperative therapy for gastric cancer affects the metastasis rate of lymph nodes (LNs) and whether the location of positive LNs affects survival after preoperative therapy. Therefore, we determined the association between positive central lymph nodes (CnLNs) and disease stage and overall survival (OS).

METHODS

We reviewed a prospectively maintained database to identify patients who had undergone resection of gastric adenocarcinoma at our institution from 2005 to 2015. CnLNs were defined as common hepatic, celiac, and proximal splenic artery LNs (stations no. 8, 9, and 11p). The frequency of CnLN metastases and risk factors affecting OS were examined.

RESULTS

We identified 356 patients. Preoperative therapy was administered to 66% of patients. D2 LN dissection was performed in 80% of patients, and the median number of LNs examined was 25 (IQR, 18-34). In 243 patients (68%), CnLNs had undergone separate pathologic examination; the CnLN-positive rate was 9.1% (22 of 243; station no. 8, 4.5%; no. 9, 2.1%; and no. 11p, 4.8%). CnLN metastasis was associated with shorter 3-year OS in patients with pN2/3 disease (33 vs. 62%; p = 0.004). Among patients who had undergone preoperative therapy, ypT3-4 stage (HR 2.44; p = 0.01) and positive CnLNs (HR 5.44; p < 0.001) were negatively associated with OS by multivariate analysis.

CONCLUSIONS

CnLN metastases are uncommon in gastric cancer and have an adverse effect on OS in patients who have undergone preoperative therapy. Larger multi-institutional studies are needed to determine whether CnLN positivity requires a separate staging category after preoperative therapy.

The prognostic value of negative lymph node count for patients with gastric cancer who received preoperative radiotherapy

Negative lymph node (NLN) count provides accurate prognostic information in patients with gastric cancer. However, it is unclear whether NLN still has prognostic value for patients received preoperative radiotherapy. In this study, Surveillance, Epidemiology, and End Results Program (SEER)-registered gastric cancer patients were used for analysis. Clinicopathological characteristics and survival time were collected. Univariate and multivariate Cox proportional hazards models were used to assess the risk factors for survival. NLN count was validated as an independent prognostic factor in both univariate and mulivariate analysis (P < 0.001). X-tile plots identified 12 as the optimal cutoff value to divide the patients into high and low risk subsets in terms of survival rate. Nomogram based on cancer-specific survival was successfully established according to all significant factors. The C-index was 0.630 (95% CI: 0.605–0.655). Subgroup analysis showed that NLN count was a prognosis factor for patients with advanced gastric cancer (stage ypII and ypIII). In conclusion, our results firmly demonstrated that NLN count was an independent prognostic factor for patients with gastric cancer who received preoperative radiotherapy. It provides more accurate prognostic information especially for patients with advanced gastric cancer (stage ypII and ypIII). Nomograms based on cancer-specific survival could be recommended as practical models to evaluate prognosis.

Negative lymph node count is an independent prognostic factor for patients with rectal cancer who received preoperative radiotherapy

Background

Negative lymph node (NLN) count has been reported to provide more accurate prognostic information than the N stage alone in patients with rectal cancer (RC). Since preoperative radiotherapy (Pre-RT) can significantly affect the LN status, it is unclear whether NLN count still has prognostic value count on survival of patients with RC who received Pre-RT.

Methods

In this study, clinicopathological characteristics, number of positive LNs and survival time were collected from Surveillance, Epidemiology, and End Results Program (SEER)-registered RC patients. Univariate and multivariate Cox proportional hazards models were used to assess the risk factors for survival.

Results

X-tile plots identified 9 (P < 0.001) as the optimal cutoff NLN value to divide the patients into high and low risk subsets in terms of cause specific survival (CSS). NLN count was validated as independently prognostic factor in univariate and multivariate analysis (P < 0.001). Subgroup analysis showed that NLN count was an independently prognostic factor for patients with stage ypII (P = 0.002) and ypIII (P < 0.001).

Conclusions

Our results firmly demonstrated that NLN count provides accurate prognostic information for RC patients with Pre-RT.

Comparison of neoadjuvant versus a surgery first approach for gastric and esophagogastric cancer

Gastric cancer remains a significant worldwide health concern. While surgery is required for cure, all but the earliest of cancers will require multimodality therapy. Chemotherapy and chemoradiation in the neoadjuvant and adjuvant settings have shown to improve overall survival, but the sequencing of treatment is controversial. As healthcare expenses surge, it is increasingly important to impart value to these treatments. This review will look at the intersection of effective treatment and costs for gastric cancer. J. Surg. Oncol. 2016;114:296-303. © 2016 Wiley Periodicals, Inc.

Adjuvant radiochemotherapy for gastric cancer: Should we use prognostic factors to select patients?

Radiotherapy has a not well-established role in the pre-operative and in the post-operative setting in gastric cancer (GC) patients. Randomized trials report controversial outcomes and impact on survival. In the D2 loco-regional node resection era, after a well-performed radical surgery, local treatment using radiotherapy combined to chemotherapy should be considered for locally advanced GC. Prognostic factors could help the better selection of subgroups that present high risk of loco-regional recurrence. Then, the addition of radiotherapy could improve the disease-free survival and also quality of life. There are no large prospective studies that have assessed specific factors predicting for recurrence or survival, but only retrospective series, some of them including high number of patients with homogeneous characteristics. In locally advanced GC adding radiotherapy to the post-operative chemotherapy seems to improve outcomes and quality of life. Prognostic factors such as T-stage, N-status, nodal ratio, and other histological factors should be considered to submit patients to post-operative combined treatment. Larger prospective series are necessary to investigate the role of combined chemoradiation after radical D2-resection, especially in locally advanced GC. Further prospective investigations are needed to suggest prognostic factors that have significant impact on survival and recurrence, improving the management and outcomes, particularly in locally advanced GC patients.

Validating the prognostic and discriminating value of the TNM-classification for gastric cancer - a critical appraisal

AIM

We investigated the effect of the new tumour-, node-, metastasis- (TNM) classification on predicting and discriminating gastric cancer patient prognosis using the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Program.

PATIENTS AND METHODS

From the SEER-database we retrieved gastric cancer patients with a primary adenocarcinoma, of Caucasian or Asian ethnicity and without distant metastases (M0). The pTNM-stage was determined according to the 7th edition of the union internationale contre le cancer (UICC) guidelines.

RESULTS

Spanning the period 2004-2010, 6136 patients fulfilled all inclusion criteria including 3424 (55.8%) men, 2712 (44.2%) women, 4629 (75.4%) Caucasian and 1507 (24.6%) Asian patients. 1524 (24.8%) patients underwent total gastrectomy and 4612 (75.2%) non-total gastrectomy. Only in 41.2% of the patients were >15 lymph nodes resected. 1857 (31.0%) patients received radiotherapy. Patient survival depended on ethnicity, type of surgery and radiotherapy. The discriminating value of the UICC-stage grouping could not be validated for Caucasian patients with >15 lymph nodes resected and who had not received radiotherapy: stage groups IIB, IIIA, IIIB and IIIC showed substantial overlap in survival ranges. In addition, the tumour specific survival of the different T-/N-combinations was significantly different in stage groups IIIB and IIIC, respectively.

CONCLUSIONS

Our retrospective analysis of the SEER-database does not validate the discriminating value of stage grouping of the 7th edition of the UICC-stage grouping. A revision should be considered and more reliable prognostic biomarkers are urgently needed.

Comparison of the efficacy and safety of S-1-based and capecitabine-based regimens in gastrointestinal cancer: a meta-analysis

PURPOSE

Oral fluoropyrimidine (S-1, capecitabine) has been considered as an important part of various regimens. We aimed to evaluate the efficacy and safety of S-1-based therapy versus capecitabine -based therapy in gastrointestinal cancers.

METHODS

Eligible studies were identified from Pubmed, EMBASE. Additionally, abstracts presented at American Society of Clinical Oncology (ASCO) conferences held between 2000 and 2013 were searched to identify relevant clinical trials. The outcome included overall survival (OS), progression-free survival (PFS), overall response rate (ORR), disease control rate (DCR) and advent events.

RESULTS

A total of 6 studies (4 RCTs and 2 retrospective analysis studies) containing 790 participants were included in this meta-analysis, including 401 patients in the S-1-based group and 389 patients in the capecitabine-based group. Results of our meta-analysis indicated that S-1-based and capecitabine-based regimens showed very similar efficacy in terms of PFS (HR 0.92, 95% CI 0.78-1.09, P = 0.360), OS (HR 1.01, 95% CI 0.84-1.21, P = 0.949), ORR (HR 1.04, 95% CI 0.87-1.25, P = 0.683) and DCR (HR 1.02, 95% CI 0.94-1.10, P = 0.639). There was also no significant difference in toxicity between regimens other than mild more hand-foot syndrome in capecitabine-based regimens.

CONCLUSION

Both the S-1-based and capecitabine-based regimens are equally active and well tolerated, and have the potential of backbone chemotherapy regimen in further studies of gastrointestinal cancers.

miR-23a targets interferon regulatory factor 1 and modulates cellular proliferation and paclitaxel-induced apoptosis in gastric adenocarcinoma cells

MicroRNAs are a class of non-coding RNAs that function as key regulators of gene expression at the post-transcriptional level. In our previous research, we found that miR-23a was significantly up-regulated in human gastric adenocarcinoma cells. In the current study, we demonstrate that miR-23a suppresses paclitaxel-induced apoptosis and promotes the cell proliferation and colony formation ability of gastric adenocarcinoma cells. We have identified tumor suppressor interferon regulator factor 1 (IRF1) as a direct target gene of miR-23a. We performed a fluorescent reporter assay to confirm that miR-23a bound to the IRF1 mRNA 3′UTR directly and specifically. The ectopic expression of IRF1 markedly promoted paclitaxel-induced apoptosis and inhibited cell viability and colony formation ability, whereas the knockdown of IRF1 had the opposite effects. The restoration of IRF1 expression counteracted the effects of miR-23a on the paclitaxel-induced apoptosis and cell proliferation of gastric adenocarcinoma cells. Quantitative real-time PCR showed that miR-23a is frequently up-regulated in gastric adenocarcinoma tissues, whereas IRF1 is down-regulated in cancer tissues. Altogether, these results indicate that miR-23a suppresses paclitaxel-induced apoptosis and promotes cell viability and the colony formation ability of gastric adenocarcinoma cells by targeting IRF1 at the post-transcriptional level.

EGF +61A>G polymorphism and gastrointestinal cancer risk: a HuGE review and meta-analysis

Emerging evidences from preclinical and clinical studies have shown that epidermal growth factor (EGF) has some effectiveness against endogenously arising carcinogenesis. Functional +61A>G polymorphism (rs4444903 A>G) in the promoter region of the EGF gene was observed to modulate EGF levels, thus affecting the susceptibility to gastrointestinal cancer; but individually published studies showed inconclusive results. The aim of this Human Genome Epidemiology (HuGE) review and meta-analysis was to derive a more precise estimation of the association between EGF +61A>G polymorphism and gastrointestinal cancer risk. A literature search of Pubmed, Embase, Web of Science and Chinese BioMedical databases from inception through July 2012 was conducted. Twelve studies were assessed with a total of 2868 gastrointestinal cancer cases and 4278 healthy controls. When all the eligible studies were pooled into the meta-analysis, the results showed that the G allele and GG genotype of EGF +61A>G polymorphism might increase the risk of gastrointestinal cancer. In the stratified analysis by cancer types, the G allele and GG genotype of EGF +61A>G polymorphism showed displayed significant correlations with increased risk of esophageal cancer. We also found significant correlations between the G carrier (GG+AG) and GG genotype of EGF +61A>G polymorphism and colorectal cancer risk. However, EGF +61A>G polymorphism did not appear to have an influence on gastric cancer susceptibility. Results from the current meta-analysis indicate that EGF +61A>G polymorphism might increase the risk of esophageal and colorectal cancers. Nevertheless, further studies are needed to determine whether genetic associations between EGF +61A>G polymorphism and susceptibility to gastric cancer are significant.

Increased survival associated with surgery and radiation therapy in metastatic gastric cancer: a Surveillance, Epidemiology, and End Results database analysis

BACKGROUND

Patients with metastatic gastric cancer have poor survival. The purpose of this study was to compare outcomes of metastatic gastric cancer patients stratified by surgery and radiation therapy.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was accessed to identify patients with AJCC M1 stage IV gastric cancer (based on the American Joint Committee on Cancer Cancer Staging Manual, 6th edition) between 2004 thru 2008. Patients were divided into 4 groups: group 1, no surgery or radiation; group 2, radiation alone; group 3, surgery alone; group 4, surgery and radiation. Survival analysis was determined by Kaplan-Meier and log-rank analysis. Multivariate analysis (MVA) was analyzed by the Cox proportional hazard ratio model.

RESULTS

A total of 5072 patients were identified. Surgery and/or radiation were associated with a survival benefit. Median and 2-year survival for groups 1, 2, 3, and 4 was 7 months and 8.2%, 8 months and 8.9%, 10 months and 18.2%, and 16 months and 31.7%, respectively (P < .00001). MVA for all patients revealed that surgery and radiation were associated with decreased mortality whereas T-stage, N-stage, age, signet ring histology, and peritoneal metastases were associated with increased mortality. In patients treated with surgery, MVA showed that radiation was associated with decreased mortality, whereas T-stage, N-stage, age, removal of < 15 lymph nodes, signet ring histology, and peritoneal metastases was associated with increased mortality. Age was the only prognostic factor in patients who did not undergo surgery.

CONCLUSIONS

Surgery and radiation are associated with increased survival in a subset of patients with metastatic gastric cancer. Prospective trials will be needed to address the role and sequence of surgery and radiation in metastatic gastric cancer.

Helicobacter pylori: gastric cancer and extragastric intestinal malignancies

The greatest challenge in Helicobacter pylori-related diseases continues to remain prevention of gastric cancer. New evidence supports the beneficial effect of H. pylori eradication not only on prevention of gastric cancer but also on the regression of preneoplastic conditions of the gastric mucosa. Concerning early detection of gastric cancer there are still no adequate means and there is urgent need to define appropriate markers, for example, by genome-wide research approaches. Currently, the best available method is the "serologic" biopsy based on pepsinogen I and the pepsinogen I/II ratio for identification of patients with severe gastric atrophy at increased risk for gastric cancer development. The treatment of early gastric cancer by endoscopic techniques can be performed safely and efficiently, but patients need meticulous follow-up for detection of metachronous lesions. In case of advanced disease, laparoscopically assisted surgical procedures are safe and favorable compared to open surgery. Two phase III trials support the role of adjuvant systemic treatment with different regimens. Unfortunately, there is still only slow progress in the development of palliative treatment regimens or modification of the existing therapy protocols. There is accumulating evidence for a role of H. pylori infection also in colorectal carcinogenesis. Seropositive individuals are at higher risk for the development of colorectal adenomas and consequently adenocarcinomas of this anatomical region. This phenomenon can partly be attributed to the increase of serum gastrin as response to atrophic changes of the gastric mucosa.