Impact of adjuvant chemotherapy in the long-term outcome of patients with resected gastric cancer

Peri-operative Outcomes and Survival Following Palliative Gastrectomy for Gastric Cancer: a Systematic Review and Meta-analysis

BACKGROUND

Many patients with gastric cancer present with late stage disease. Palliative gastrectomy remains a contentious intervention aiming to debulk tumour and prevent or treat complications such as gastric outlet obstruction, perforation and bleeding.

METHODS

We conducted a systematic review of the literature for all papers describing palliative resections for gastric cancer and reporting peri-operative or survival outcomes. Data from peri-operative and survival outcomes were meta-analysed using random effects modelling. Survival data from patients undergoing palliative resections, non-resective surgery and palliative chemotherapy were also combined. This study was registered with the PROSPERO database (CRD42019159136).

RESULTS

One hundred and twenty-eight papers which included 58,675 patients contributed data. At 1 year, there was a significantly improved survival in patients who underwent palliative gastrectomy when compared to non-resectional surgery and no treatment. At 2 years following treatment, palliative gastrectomy was associated with significantly improved survival compared to chemotherapy only; however, there was no significant improvement in survival compared to patients who underwent non-resectional surgery after 1 year. Palliative resections were associated with higher rates of overall complications versus non-resectional surgery (OR 2.14; 95% CI, 1.34, 3.46; p < 0.001). However, palliative resections were associated with similar peri-operative mortality rates to non-resectional surgery.

CONCLUSION

Palliative gastrectomy is associated with a small improvement in survival at 1 year when compared to non-resectional surgery and chemotherapy. However, at 2 and 3 years following treatment, survival benefits are less clear. Any survival benefits come at the expense of increased major and overall complications.

Relationship between Clavien-Dindo classification and long-term survival outcomes after curative resection for gastric cancer: A propensity score-matched analysis

BACKGROUND

The impact of postoperative complications (POCs) on the long-term survival outcomes after curative resection for gastric cancer has seldom been reported. The purpose of this study was to evaluate the relationship between the severity of POCs and long-term survival outcomes after curative resection for gastric cancer.

METHODS

The study analyzed 3091 patients who underwent curative resection for gastric cancer in a single center between June 2009 and June 2015. Patients were divided into two groups based on the occurrence or absence of postoperative complications which were recorded using the Clavien-Dindo classification. Long-term survival outcomes were compared between groups after propensity score matching (PSM).

RESULTS

A total of 3091 patients were included in the entire cohort. After PSM, no significant difference in baseline data was observed between the complications (C) group (n = 375) and no complications (NC) group (n = 375). With a median follow-up of 51 months, POCs were associated with decreased 5-year overall survival (OS) (51.7% vs. 67.5%, P < 0.001), disease-free survival (DFS) (49.9% vs. 65.6%, P < 0.001), and disease-specific survival (DSS) (53.9% vs. 68.8%, P < 0.001). Increasing Clavien-Dindo grades from II to IV was significantly associated with a corresponding decrease in OS (60, 48.3, 34%, P = 0.010), DFS (58.3, 46.3, 32.1%, P < 0.001) and DSS (62.9, 50.3, 34%, P < 0.001). Multivariate analysis confirmed POCs was an independent prognostic factor for decreased OS, DFS, and DSS (all P < 0.05).

CONCLUSIONS

POCs had a negative impact on long-term survival outcomes after curative resection for gastric cancer. The negative effects were also increased with higher Clavien-Dindo grades.

Clinical impact of underutilization of adjuvant therapy in node positive gastric adenocarcinoma

Background

Adjuvant therapy for gastric adenocarcinoma has shown a survival advantage, though it may be underutilized. The purpose of this study is to examine how infrequently adjuvant therapy is administered with curative intent gastrectomy for node positive gastric cancer and the long-term effects to patients.

Methods

The National Cancer Database was queried from 2006-2013 for patients with node positive gastric adenocarcinoma undergoing a potentially curative gastrectomy. Overall survival was compared between patients who received adjuvant chemotherapy or chemoradiation and those who did not.

Results

Of 2,565 patients, 793 (30.9%) patients did not receive any adjuvant chemotherapy or radiation therapy, while 147 (5.7%) received peri-operative chemotherapy and 723 (28.2%) received post-operative chemoradiation. From 2006-2013, the percentage of patients receiving peri-operative chemotherapy rose from 1.1% to 9.9%, while those receiving post-operative chemoradiation decreased from 39.7% to 21.6%. The adjusted restricted mean survival time over 5 years for no adjuvant therapy was 27.7 months, peri-operative chemotherapy was 39.6 months, and post-operative chemoradiation was 37.7 months (P<0.0001).

Conclusions

Approximately one third of patients treated for node positive gastric cancer undergo surgical resection without adjuvant therapy. This is associated with poorer survival, highlighting the need for improvement in multimodality care and cancer outcomes.

Postoperative complications do not impact on recurrence and survival after curative resection of gastric cancer

BACKGROUND

We assessed the impact of complications on recurrence and survival after curative gastric cancer resection.

METHODS

Patients undergoing R0 resections between 1990 and 2009 were identified in a prospectively maintained database and were categorized by presence of any complication Clavien-Dindo (CD) ≥ II, sepsis or intra-abdominal sepsis. Cox regression analyses to relate complications and clinico-pathological variables to time to recurrence (TTR) and overall survival (OS) were performed.

RESULTS

A total of 271 patients were included with a median follow-up of 149.9 months (range 140.1-159.9). Complications CD ≥ II occurred in 162 (59.8%) patients, sepsis in 66 (22.5%), and intra-abdominal sepsis in 37 (13.6%). Recurrence developed in 88 (32.4%) patients. Independent predictors of short TTR were pTNM stage (IIIB-IIIC vs. IA-IIA) (hazard ratio [HR] = 37.55, 95% confidence interval [CI] 17.57-80.24; p < 0.001), D1 lymphadenectomy (HR = 3.14, 95% CI 1.94-5.07; p < 0.001), and male gender (HR = 1.65, 95% CI 1.06-2.57; p = 0.026). pTNM stage (IIIB-IIIC vs. IA-IIA, HR = 10.28, 95% CI 6.51-16.23; p < 0.001), male gender (HR = 1.64, 95% CI 1.17-2.31; p = 0.005), age (HR = 1.03, 95% CI 1.02-1.05; p < 0.001), and adjuvant therapy (HR = 0.55, 95% CI 0.37-0.83; p = 0.004) were identified as independent predictors of OS..

CONCLUSIONS

Evidence provided by this study does not support a negative impact of postoperative complications CD ≥ II, sepsis, and intra-abdominal sepsis on the oncologic outcome after curative gastric cancer resection.

Solitary rib recurrence of hilar cholangiocarcinoma 10 years after resection: report of a case

A 61-year-old female underwent right hemihepatectomy and caudate lobectomy for hilar cholangiocarcinoma in 1999. Ten years later, increasing serum carbohydrate 19-9 was detected by routine follow-up. Subsequent positron emission tomography revealed an asymptomatic lesion in the right 11th rib. As the mass steadily grew in size, the lesion was resected en bloc with the affected rib and muscle. The histopathological findings closely resembled those of the primary cholangiocarcinoma. Thus, the tumor was diagnosed as a metastatic recurrence 10 years after resection of the primary tumor. There have been a few reports of cholangiocarcinoma recurrence in long-term survivors at the surgical margins, peritoneum, or transhepatic drainage route. However, there are no reports of solitary extra-abdominal recurrence. This case highlights the need for careful follow-up of patients with cholangiocarcinoma and nodal metastasis, even in the absence of recurrence for >5 years after curative resection.

The effect of locoregional transarterial infusion chemotherapy on liver metastasis after gastric cancer resection

OBJECTIVE

A retrospective clinical study to evaluate the effect of transarterial infusion (TAI) chemotherapy and transarterial chemoembolization (TACE) on liver metastasis after gastric cancer resection.

METHODS

The study recruited patients who underwent surgical resection for stage T(2)N(2)M(0) gastric adenocarcinoma without liver metastasis. Patients chose to receive either TAI or systemic chemotherapy, based on the advantages and disadvantages of each regimen as explained by physicians. Both regimens comprised 100 mg/m2 oxaliplatin and 500 mg/m2 fluorodeoxy uridine, administered via TAI or a peripheral vein, commencing 30 days postsurgery. Patients who developed liver metastasis during the 3-year follow-up period were offered TACE.

RESULTS

Mean time from gastric cancer diagnosis to liver metastasis was significantly longer in the TAI group (n = 13) than in the systemic chemotherapy group (n = 29); 944 ± 231 days versus 506 ± 77 days. Patients who received TACE (n = 32) had a partial remission rate of 46.9% and a median survival of 14.7 months after diagnosis of liver metastasis.

CONCLUSIONS

Locoregional TAI chemotherapy was more effective in reducing liver metastasis after gastric cancer resection than conventional systemic chemotherapy. TACE is an effective treatment for liver metastasis.

Changing patterns of prognosticators during 15-year follow-up of advanced gastric cancer after radical gastrectomy and adjuvant chemotherapy: a 15-year follow-up study at a single korean institute

BACKGROUND

We evaluated the long-term natural history of gastric cancer after radical gastrectomy and adjuvant chemotherapy through a 15-year follow-up study at a single institute.

METHODS

Five hundred patients with advanced gastric adenocarcinoma who received radical gastrectomy and adjuvant chemotherapy were included in this long-term follow-up study. Patients were evaluated by imaging studies and upper gastrointestinal series or endoscopy every 6 months until the 10th year after surgery. Since then, the patients have been followed yearly in the same manner.

RESULTS

The median follow-up period was 190.5 months. The recurrence rate in 5-year survivors was 10.8%. The dominant recurrence pattern was peritoneal carcinomatosis within 5 years and distant metastasis after 5 years post gastrectomy. Tumor stage was a clear-cut prognosticator within 5 years post gastrectomy, but was no longer informative in 5-10 years. At this period, only stage IV (IB-IIIB vs IVM0) was a significantly poor prognosticator. After 10 years, second primary cancer (seven cases) became as important an issue as recurrence of primary gastric cancer (six cases).

CONCLUSIONS

In patients with gastric carcinoma treated with radical gastrectomy and adjuvant chemotherapy, late recurrence after 5 years post gastrectomy was not rare. Prognosticators were varied depending on the length of time after surgery. Tumor factors including stage were prognosticators within 5 years post gastrectomy, but tumor factors except stage IV had no prognostic value after 5 years. In the 5-10 years post gastrectomy, only stage IV (IB-IIIB vs IVM0) was a poor prognosticator. Also, after 10 years, there were no prognosticators.

Time-related improvement of survival in resectable gastric cancer: the role of Japanese-style gastrectomy with D2 lymphadenectomy and adjuvant chemotherapy

BACKGROUND

We investigated the change of prognosis in resected gastric cancer (RGC) patients and the role of radical surgery and adjuvant chemotherapy.

METHODS

We retrospectively analyze the outcome of 426 consecutive patients from 1975 to 2002, divided into 2 time-periods (TP) cohort: Before 1990 (TP1, n = 207) and 1990 or after (TP2; n= 219). Partial gastrectomy and D1-lymphadenectomy was predominant in TP1 and total gastrectomy with D2-lymphadenectomy it was in TP2. Adjuvant chemotherapy consisted of mitomycin C (MMC), 10-20 mg/m2 i.v. 4 courses or MMC plus Tegafur 500 mg/m2 for 6 months.

RESULTS

Positive nodes were similar in TP2/TP1 patients with 56%/59% respectively. Total gastrectomy was done in 56%/45% of TP2/TP1 respectively. Two-drug adjuvant chemotherapy was administered in 65%/18% of TP2/TP1 respectively. Survival at 5 years was 66% for TP2 versus 42% for TP1 patients (p < 0.0001). Survival by stages II, IIIA and IIIB for TP2 versus TP1 patients was 70 vs. 51% (p = 0.0132); 57 vs. 22% (p = 0.0008) and 30 vs. 15% (p = 0.2315) respectively. Multivariate analysis showed that age, stage of disease and period of treatment were independent variables.

CONCLUSION

The global prognosis and that of some stages have improved in recent years with case RGC patients treated with surgery and adjuvant chemotherapy.

A review of adjuvant therapy for resected primary gastric cancer with an update on Taegu's phase III trial with intraperitoneal chemotherapy

AIMS

Because patients with advanced gastric cancers have less than 50% chance of cure after R0 resection, the need for an adjuvant treatment to eradicate residual microscopic disease is clear. The major treatment strategy during the last decades has been postoperative systemic therapy. The results of published trials were reviewed. And, perioperative intraperitoneal chemotherapy as an adjuvant to potentially curative surgery was evaluated.

METHODS

A literature search on this topic was performed for articles relating to clinical trials using adjuvant chemotherapy in the management of gastric cancer. Subset analyses of Taegu's phase III trial of early postoperative intraperitoneal chemotherapy were performed.

RESULTS

Even after extended lymphadenectomy, the peritoneal surface and resection site had a high incidence of recurrence. Postoperative systemic chemotherapy treatment regimens available in the past showed no major improvement in survival. One of new approaches currently undergoing study was intraperitoneal chemotherapy given in the perioperative period. The Taegu data showed this treatment reduced the incidence of peritoneal recurrence and thereby improved the survival rate after potentially curative surgery for gastric cancer.

CONCLUSIONS

The eradication of micrometastatic foci in the peritoneal cavity can be achieved by the perioperative intraperitoneal administration of chemotherapeutic agents. Patients with serosa-positive gastric cancer are most likely to benefit from adjuvant intraperitoneal chemotherapy.

Expression of carbonic anhydrase IX (CA IX), a hypoxia-related protein, rather than vascular-endothelial growth factor (VEGF), a pro-angiogenic factor, correlates with an extremely poor prognosis in esophageal and gastric adenocarcinomas

OBJECTIVE

To evaluate the expression of carbonic anhydrase IX (CA IX) and vascular-endothelial growth factor (VEGF) in esophageal and gastric adenocarcinomas and in turn with the histologic subtype.

SUMMARY BACKGROUND DATA

Tumor hypoxia is an important factor in therapy resistance. A low oxygen concentration in tumors stimulates a.o. the expression of CA IX, a marker of hypoxia, and VEGF, a pro-angiogenic factor.

METHODS

We evaluated the immunohistochemical expression of CA IX and VEGF on paraffin-embedded material of 154 resection specimens: 39 esophageal, 73 cardiac, and 42 distal gastric adenocarcinomas (UICC classification). The adenocarcinomas were subtyped according to the Lauren classification (intestinal- and diffuse-type).

STATISTICAL ANALYSIS

chi test, Kaplan-Meier survival analysis, log-rank test, and Cox proportional hazards model.

RESULTS

CA IX and VEGF expression were independent of the localization of the tumor. However, intestinal-type adenocarcinomas showed a significantly higher expression of CA IX as well as VEGF than diffuse-type tumors. VEGF expression was associated with a high microvessel density. Although survival analysis showed that CA IX expression (P = 0.008) as well as the coexpression of CA IX and VEGF (P = 0.008) correlate with a poor outcome, only CA IX expression is an independent prognostic factor for overall survival and metastasis-free survival.

CONCLUSION

The difference in expression of CA IX and VEGF between intestinal- and diffuse-type adenocarcinomas may possibly explain the different clinical behavior of these tumors. CA IX expression, rather than VEGF positivity in tumors, enables the identification of a subpopulation, characterized by a more aggressive behavior and a poorer prognosis.

Gastric cancer confined to the muscularis propria: a possible candidate for laparoscopic surgery or adjuvant therapy

OBJECTIVE

Gastric cancer confined to the muscularis propria (mp) has a favorable prognosis, but still belongs to the advanced category. Many oncologists have difficulties in selecting treatment modalities owing to the confused situation of mp cancer. To clarify the therapeutic strategy, the clinicopathological characteristics were investigated, and the risk factors, of this intermediate-stage gastric cancer, evaluated.

MATERIAL AND METHODS

A total of 155 patients who underwent curative resection for primary gastric cancer between 1993 and 2001 were diagnosed with mp cancer. The patients were divided into recurrent and non-recurrent groups and analyzed clinicopathologically.

RESULTS

The rate of recurrence was 20%. A multivariate analysis disclosed only lymphatic metastasis as an independent risk factor for recurrence of mp cancer. Hematogenous metastasis accounted for 37% of the recurrent patterns, and the liver (83.3%) was the most common organ. The 5-year survival rate of all mp cancer patients was 80.9%, but that of patients with recurrent disease was 19.2%. The median survival time of the recurred patients was 24 months, and 74% of those patients died within 3 years.

CONCLUSIONS

Lymph node metastasis is the only significant risk factor of mp cancer. Patients with lymphatic metastasis should undergo postoperative adjuvant therapy. On the other hand, patients with mp cancer without lymph node involvement have an excellent prognosis and could be candidates for laparoscopic gastric surgery.