Selection of best candidates for multiorgan resection among patients with T4 gastric carcinoma

Prognostic Factors of Survival in Patients With Gastric Cancer Under 45 Years Old Treated With Surgery in a Single Center in Mexico City

Introduction Gastric cancer is a significant major global health concern, particularly prevalent in Asia. In recent years, a large number of new cases have been diagnosed worldwide, leading to a substantial number of deaths. The disease tends to present more aggressively in these cases, leading to debates about the prognosis and survival outcomes. Nonetheless, research has shown that survival rates improve significantly when the tumor is completely surgically resected. Materials and methods This retrospective study included patients between 16 and 45 years old, diagnosed with gastric cancer, with the support of the pathology department, who underwent surgery in the upper GI service, in the period from January 2006 to December 2012. Data collected encompassed variables such as gender, age, tumor size, type of surgery, overall survival, disease-free period, type and histological degree of the tumor, clinical stage of the cancer, and R0 resection (curative resection). All patients with a confirmed diagnosis of gastric cancer were included and treated with surgery and D1 limited dissection or extended D2 dissection. Patients who have received chemotherapy prior to surgical treatment and those who have been surgically treated outside the XXI Century National Medical Center were excluded. Results A total of 104 patients were included; the predominant histological type was diffuse adenocarcinoma accounting for 79.8% and 81.7% of the cases were histological grade 3. The most common clinical stage was IIIA in 41.3% of the cases. In 53.8% of the cases, we obtained an R0 resection. D2 lymphadenectomy was performed in 53.8% of the cases, with an overall survival rate of 82.69%. Significant prognostic factors for survival included T4 depth with an increase in risk for mortality (OR: 25.93; 95% CI: 6.41-53.54; p=0.001), lymph node status (OR: 14.76; 95% CI: 4.6-46.83; p<0.001), and size greater than 5 cm (OR: 1.8; 95% CI: 0.61-6.35; p<0.001). Conclusions Gastric cancer is more common in adults aged above 60 years old, but the incidence in young adults under 45 years old has been increasing. Although young gastric cancer patients present with more aggressive tumor behavior, these patients can have similar or even better overall survival compared to older patients, being 35% in some cases, especially in the resectable setting. Further research is still needed to fully characterize the unique biology and optimal management of gastric cancer in young adults.

What determines complications and prognosis among patients subject to multivisceral resections for locally advanced gastric cancer?

BACKGROUND

Locally advanced gastric cancer (GC) extending to the surrounding tissues may require a multivisceral resection (MVR) to provide the best chance of cure. However, little is known about how the extent of organ resection affects the risks and benefits of surgery.

METHODS

An electronic database of patients treated between 1996 and 2020 in an academic surgical centre was reviewed. MVRs were defined as partial or total gastrectomy combined with splenectomy, distal pancreatectomy, or partial colectomy.

RESULTS

Suspected intraoperative tumour invasion of perigastric organs (cT4b) was found in 298 of 1476 patients with non-metastatic GC, and 218 were subject to MVRs, including the spleen (n = 126), pancreas (n = 51), and colon (n = 41). MVRs were associated with higher proportions of surgical and general complications, but not mortality. A nomogram was developed to predict the risk of major postoperative morbidity (Clavien-Dindo's grade ≥ 3a), and the highest odds ratio for major morbidity identified by logistic regression modelling was found for distal pancreatectomy (2.53, 95% CI 1.23-5.19, P = 0.012) and colectomy (2.29, 95% CI 1.04-5.09, P = 0.035). Margin-positive resections were identified by the Cox proportional hazards model as the most important risk factor for patients' survival (hazard ratio 1.47, 95% CI 1.10-1.97). The extent of organ resection did not affect prognosis, but a MVR was the only factor reducing the risk of margin positivity (OR 0.44, 95% CI 0.21-0.87).

CONCLUSIONS

The risk of multivisceral resections is associated with the organ being removed, but only MVRs increase the odds of complete tumour clearance for locally advanced gastric cancer.

Impact of surgical resection on the survival in Mexican patients with gastric cancer: A meta-analysis and systematic review

BACKGROUND

Gastric cancer (GC) is one of the most frequent cancer types in Mexico. The primary method used as a treatment is surgical resection. The role of surgery in increasing survival is controversial. This study aimed to determine whether surgical resection increases the survival of patients with GC in a Mexican population.

METHODS

A systematic review of literature searches (Evidence-based MEDLINE/PubMed, Web of Science, Cochrane Library, and SciELO) and meta-analysis were performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis criteria. The published articles from 2000 to the current time were divided into cross-sectional and randomized studies. The inclusion criteria were survival, surgical resections, patients treated in Mexico, and primary GC. The effect estimation was calculated using the risk ratio (RR). The random-effects model and a confidence interval (CI) of 95% were used.

RESULTS

The RR of the pooled studies was 1.09 (95% CI, 0.71-1.67). RR of 0.82 (95% CI, 0.63-1.07) was obtained in cross-sectional studies, and randomized studies showed a RR of 2.08 (95% CI, 0.25-17.07).

CONCLUSION

This work is the first systematic study that assesses the role of surgery on the survival of patients with GC in the Mexican population, the results showed that surgical resection did not improve survival in patients with GC.

Аre Multivisceral Resections for Gastric Cancer Acceptable: Experience from a High Volume Center and Extended Literature Review?

Introduction  Multivisceral resections (MVRs) in gastric cancer are potentially curable in selected patients in whom clear resection margins are possible. However, there are still uncertain data on their feasibility and safety considering short- and long-term results. The study compares survival, morbidity, mortality, and other secondary outcomes between standard and MVRs for gastric cancer. Materials and Methods  A monocentric retrospective study in patients with gastric adenocarcinoma, covering 2004 to 2020. Of the 336 operable cases, 101 patients underwent MVRs. The remaining 235 underwent standard gastric resections (SGRs), of which 173 patients were in stage T3/T4. To compare survival, a control group of 101 patients with palliative procedures was used-bypass anastomosis or exploration. Results  MVR had a lower survival rate than the SGR but significantly higher than the palliative procedures. The predominant gender in MVR was male (72.3%), with a mean age of 61 years. The perioperative mortality was 3.96% ( n  = 4), and the overall median survival was 28.1 months. The most frequently resected organs were the spleen (67.3%), followed by the pancreas (32.7%) and the liver (20.8%). In 56.4% of the cases two organs were resected, in 28.7% three organs, and in 13.9% four organs. The main complication was bleeding (9.9%). The major postoperative complications in the MVR were 14.85%, and in the SGR 6.4% ( p  < 0.05). Better long-term results were observed in patients who underwent R0 resections compared with R1. Conclusion  Multiorgan resections are characterized by poorer survival and a higher complication rate than gastrectomies. On the other hand, they have better long-term outcomes than palliative procedures. However, MVRs are admissible when performed by an experienced surgical team in high-volume centers.

Association between Inflammatory Markers and Local Recurrence in Patients with Giant Cell Tumor of Bone: A Preliminary Result

Giant cell tumor of bone (GCTB) has a high local recurrence rate of approximately 20%. Systemic inflammatory markers, such as neutrophil-lymphocyte ratio (NLR), modified Glasgow prognostic score (mGPS), prognostic nutritional index (PNI), lymphocyte-monocyte ratio (LMR), platelet-lymphocyte ratio (PLR), hemoglobin (Hb), alkaline phosphatase (ALP), and lactate dehydrogenase (LDH), have been reported as prognostic markers in patients with malignant tumors. This study aimed to investigate the correlation between these markers and the local recurrence rate of GCTB. In total, 103 patients with GCTB who underwent surgery at the authors' institutions between 1993 and 2021 were included. Thirty patients experienced local recurrence. Univariate and multivariate analysis showed that tumor site, preoperative and postoperative denosumab treatment, and surgery were significantly associated with local recurrence-free survival. LDH was associated with local recurrence-free survival on univariate analysis only. NLR, mGPS, PNI, LMR, and PLR score did not correlate with the local recurrence rate. In conclusion, NLR, mGPS, PNI, LMR, PLR score, Hb, ALP, and LDH levels are not correlated with the local recurrence rate of GCTB. However, due to the small number of patients included in this study, this result should be re-evaluated in a multicenter study with a larger sample size.

Gastric Cancer Invading the Pancreas: A Review of the Role of Pancreatectomy

Gastric cancer is quite a common type of cancer, with significant associated mortality. Traditionally, combined resections of affected organs have been advocated in cases of locally advanced gastric cancer, in order to achieve an R0 resection. The purpose of the present study was to evaluate the role of pancreatectomy in the treatment of gastric cancer invading the pancreas by reviewing the relevant literature. The oncological benefits to survival rates of multivisceral resection are not always obvious from the relevant survival charts, especially when the pancreas is the organ invaded by the gastric cancer and gastrectomy needs to be combined with a pancreatectomy, an operation with high morbidity rates. In conclusion, careful patient selection is essential to achieving optimal results, balancing the oncological benefits in these properly selected patients against the associated morbidity of extensive resection.

Pre-operative prognostic nutritional index was associated with recurrence after surgery in giant cell tumor of bone patients

Objectives

Giant cell tumors of bone (GCT) are benign with a local recurrence rate of approximately 20-50%. Growing evidence suggests that inflammation plays an important role in tumor formation and progression. Inflammatory biomarkers, including prognostic nutritional index (PNI), neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR), have little data in predicting postoperative recurrence of GCT.

Methods

We retrospectively investigated 105 patients with surgery for GCT between March 2010 and June 2019 at our hospital. Through the analysis of receiver operating characteristics (ROC), the optimal cutoff values of PNI, NLR and PLR were determined. Clinical features between PNI, NLR and PLR were tested with the χ² test. Univariate and multivariate analyses were applied to identify the prognostic factors.

Results

The optimal cut-off points of PNI, NLR and PLR were 48.6, 2.4 and 136.9, respectively. In univariate analysis, PNI, NLR, PLR, tumor size, Campanacci stage were significantly associated with recurrence-free survival (RFS). Cox multivariate regression analysis revealed that the PNI (p = 0.003) and Campanacci stage (p = 0.001) were independent prognostic factors for GCT.

Conclusions

PNI can be regarded as a novel independent prognostic factor for predicting postoperative recurrence in GCT.

Multivisceral resection for locally advanced gastric cancer: A retrospective study

BACKGROUND

Multivisceral resection may be the exclusive radical procedure for cT4b gastric cancer patients. However, most surgeons refuse to select surgery because of the theoretical higher mortality, morbidity and poorer prognosis.

METHODS

We retrospectively reviewed cT4b gastric cancer patients who underwent surgery from January 1,1997 to December 31,2018. The primary endpoint was overall survival. Short-term results and prognostic values of clinical and pathologic factors were also analyzed.

RESULTS

Patients underwent multivisceral resection had an acceptable mortality and morbidity. The overall 5-year survival rate of multivisceral resection was higher than that of palliative surgery (P < 0.05). And independent prognostic factors of multivisceral resection were R+ resection, extensive lymph node involved (>15), vascular cancer emboli, and postoperative chemotherapy.

CONCLUSIONS

cT4b gastric cancer patients underwent multivisceral resection experience acceptable mortality and morbidity. The independent prognostic factors for multivisceral resection were completeness of resection, extensive lymph node involvement (>15), vascular cancer emboli, and postoperative chemotherapy.

Multivisceral resection vs standard gastrectomy for gastric adenocarcinoma

INTRODUCTION

Multivisceral resection (MVR) is potentially curative for selected gastric cancer patients, supposedly at the cost of increased complications. However, current data comparing MVR to standard gastrectomy (SG) is lacking.

OBJECTIVES

Compare complications and survival after MVR and SG.

METHODS

In a retrospective cohort of 1015 patients with gastric adenocarcinoma, 58 underwent MVR and 466 SG. Groups were compared concerning their characteristics, complications, and survival.

RESULTS

One hundred seventy-six patients had postoperative complications. Major complications were more frequent after MVR (P = .002). Surgical mortality was 8.6% and 4.9% for MVR and SG (P = .221). Older age, higher morbidities, and MVR were independent risk factors for major complications. The odds ratio for major complications was 5.89 for MVR with one or two organs and 38.01 for MVR with three or more organs. The pancreas was the most commonly removed organ and pT4b disease were confirmed in 34 (58.6%) of the MVR cases. Disease-free survival (DFS) was lower in MVR patients (51% vs 77.8%; P < .001), being worse according to the number of organs resected. In pN+ patients, DFS was worse after MVR. DFS was equivalent to pT4b and non-pT4b in the MVR group.

CONCLUSIONS

Increased morbidity and lower survival are expected for gastric cancer patients undergoing MVR.

Significance of multivisceral resections in oncologic surgery: A systematic review of the literature

BACKGROUND

Multivisceral resections (MVR) are often necessary to reach clear resections margins but are associated with relevant morbidity and mortality. Factors associated with favorable oncologic outcomes and elevated morbidity rates are not clearly defined.

AIM

To systematically review the literature on oncologic long-term outcomes and morbidity and mortality in cancer surgery a systematic review of the literature was performed.

METHODS

PubMed was searched for relevant articles (published from 2000 to 2018). Retrieved abstracts were independently screened for relevance and data were extracted from selected studies by two researchers.

RESULTS

Included were 37 studies with 3112 patients receiving MVR for colorectal cancer (1095 for colon cancer, 1357 for rectal cancer, and in 660 patients origin was not specified). The most common resected organs were the small intestine, bladder and reproductive organs. Median postoperative morbidity rate was 37.9% (range: 7% to 76.6%) and median postoperative mortality rate was 1.3% (range: 0% to 10%). The median conversion rate for laparoscopic MVR was 7.9% (range: 4.5% to 33%). The median blood loss was lower after laparoscopic MVR compared to the open approach (60 mL vs 638 mL). Lymph-node harvest after laparoscopic MVR was comparable. Report on survival rates was heterogeneous, but the 5-year overall-survival rate ranged from 36.7% to 90%, being worst in recurrent rectal cancer patients with a median 5-year overall survival of 23%. R0 -resection, primary disease setting and no lymph-node or lymphovascular involvement were the strongest predictors for long-term survival. The presence of true malignant adhesions was not exclusively associated with poorer prognosis.

Included were 16 studies with 1.600 patients receiving MVR for gastric cancer. The rate of morbidity ranged from 11.8% to 59.8%, and the main postoperative complications were pancreatic fistulas and pancreatitis, anastomotic leakage, cardiopulmonary events and post-operative bleedings. Total mortality was between 0% and 13.6% with an R0 -resection achieved in 38.4% to 100% of patients. Patients after R0 resection had 5-year overall survival rates of 24.1% to 37.8%.

CONCLUSION

MVR provides, in a selected subset of patients, the possibility for good long-term results with acceptable morbidity rates. Unlikelihood of achieving R0 -status, lymphovascular- and lymph -node involvement, recurrent disease setting and the presence of metastatic disease should be regarded as relative contraindications for MVR.

Extended Gastrectomy for T4b Gastric Adenocarcinoma: Single-Surgeon Experience

PURPOSE

This study reports single-surgeon experience with extended gastrectomy including en-bloc resection of adjacent organs/structures for T4b stage gastric adenocarcinoma. Time-related changes in patient selection criteria and outcomes were also analyzed.

METHODS

All consecutive gastrectomies for adenocarcinoma performed between May 2004 and December 2017 were extracted from prospectively collected database to study surgical and oncologic results. Time-related changes in outcomes were examined according to three time periods.

RESULTS

Five hundred eighty-seven gastrectomies were performed throughout the study period including 87 (14.8%) extended resections. The latter most often included pancreatosplenectomy, colon, and liver resections (21, 16, and 11 patients, respectively) resulting in similar postoperative outcomes and survival. Extended gastrectomy was associated with larger tumor size (8.4 vs 5.6 cm), performing total gastrectomy (55.2 vs 35.2%, p < 0.01) and increased blood loss (375 vs 150 ml, p < 0.01) compared with standard gastrectomy. Larger experience in extended gastrectomy allowed for expanding patient selection criteria, considering complex resections and extensive lymphadenectomy. Median and 3-year survival following extended gastrectomy for T4b adenocarcinoma were 14 months and 18%, respectively, which was comparable to standard gastrectomy for T4a adenocarcinoma (p = 0.48). Obesity, nodal stage and type of gastrectomy were associated with survival in T4b adenocarcinoma in the univariable analysis. Obesity and N3a and N3b stages were independent predictors in the multivariable model.

CONCLUSIONS

Extended gastrectomy for T4b gastric adenocarcinoma provides satisfactory surgical outcomes even with expanded patient selection criteria and regardless of the organ involved. Given its poor prognosis, neoadjuvant therapy should be considered to improve the long-term oncologic results.

Multivisceral Resection for Locally Advanced Gastric and Gastroesophageal Junction Cancers-11-Year Experience at a High-Volume North American Center

INTRODUCTION

The oncologic benefit of multivisceral en bloc resections for T4 gastroesophageal tumors has been questioned, given the increased morbidity associated. We thus sought to investigate the surgical and oncologic outcomes of curative-intent en bloc multivisceral resections for T4 gastroesophageal carcinomas.

METHODS

Between 2005 and 2016, 35 of the 525 patients who had gastric or EGJ carcinomas underwent curative-intent multivisceral resections for direct invasion or adhesion to adjacent organs.

RESULTS

Postoperative complications occurred in 16(46%), 10 of which were Clavien-Dindo ≥ 3 (29%). Ninety-day mortality was 3%. The R0 resection rate was 94% (33). Direct organ invasion (pT4b) was confirmed on pathological analysis in 14 (40%) and did not affect survival. The majority (28, 80%) had lymph node involvement with a high nodal disease burden and was associated with decreased survival. Overall 5-year survival rate was 34%, and the vast majority of recurrences were distant/peritoneal (81%). On multivariate analysis, positive lymph nodes (H.R. 21.2; 95%CI 2.34-192) and R1 resection (H.R. 5.6; 95%CI 1.02-30.9) were predictors of survival.

CONCLUSION

Multivisceral resections for T4 gastric and GEJ adenocarcinomas, in combination with effective systemic therapy, result in prolonged long-term survival with acceptable morbidity. Complete resection to negative margins should remain a mainstay of curative-intent treatment in carefully selected patients.

Impact of clinicopathological parameters on survival after multiorgan resection among patients with T4 gastric carcinoma: a systematic review and meta-analysis

BACKGROUND

The prognostic factors which can improve the overall survival (OS) of patients with T4 gastric carcinoma (GC) are still controversial: a meta-analysis was conducted to analyze the impact of clinicopathological parameters on survival after MOR among patients with T4 GC.

METHODS

A systematic search was performed. Odd risks (ORs) of patients with T4 GC were used to calculate the relationship between clinicopathological parameters and OS.

RESULTS

Nine studies involving 941 patients with T4 GC were identified. Well-moderate differentiation led to increased 1-, 3-, 5-year OS with an OR of 2.63, 1.58 and 1.45. Borrmann type I-II led to increased 1-, 3-year OS with an OR of 1.67 and 2.08. No lymph node metastasis led to increased 1-, 3-, 5-year OS with an OR of 7.16, 3.18 and 3.71. Total gastrectomy led to increased 1-, 3-year OS with an OR of 2.01 and 1.79. ≥2 Organs resected led to increased 1-, 3-year OS with an OR of 2.19 and 2.19. TNM stage II-III led to increased 1-, 3-year OS with an OR of 3.68 and 5.75. Curative resection led to increased 1-, 3-, 5-year OS with an OR of 4.46, 5.80 and 5.98.

CONCLUSION

Well-moderate differentiation, Borrmann type I-II, no lymph node metastasis, total gastrectomy, ≥2 organs resected, TNM stage II-III and curative resection were positive prognostic factors for OS of patients with T4 GC.

Multivisceral Resection for Gastric Cancer: Results from the US Gastric Cancer Collaborative

BACKGROUND

Resection of an adjacent organ during gastrectomy for gastric cancer is occasionally necessary to achieve margin clearance. The short- and long-term outcomes of this approach remain unclear.

METHODS

Patients who underwent gastric cancer resection in seven U.S. academic institutions from 2000 to 2012 were evaluated to compare perioperative morbidity, mortality, and survival outcomes, stratified by the need for and type of multivisceral resection (MVR).

RESULTS

Of 835 patients undergoing curative-intent gastrectomy, 159 (19 %) had MVR. The most common adjacent organs resected were the spleen (48 %), pancreas (27 %), liver segments 2/3 (14 %), and colon (13 %). As extent of resection increased (gastrectomy only, n = 676; MVR without pancreatectomy, n = 116; and MVR with pancreatectomy, n = 43), perioperative morbidity was higher: any complication (45, 60, 59 %, p = 0.012), major complication (17, 31, 33 %, p = 0.001), anastomotic leak (5, 11, 19 %, p < 0.001), and respiratory failure (9, 15, 22 %, p = 0.012). However, perioperative mortality did not significantly increase (30-day: 3, 4, 2 %, p = 0.74; 90-day: 6, 8, 9 %, p = 0.61). Overall survival after resection decreased as extent of resection increased (5-year: 42, 28, 6 %). After controlling for age, race, T stage, N stage, grade, margin status, perineural invasion, adjuvant therapy, and blood transfusion, MVR with pancreatectomy (HR 1.67, p = 0.044), but not MVR without pancreatectomy (HR 0.97, p = 0.759), remained an independent predictor of poor survival.

CONCLUSION

In this modern, multi-institutional cohort of gastric cancer patients, multivisceral resection was associated with higher perioperative morbidity but not significantly higher perioperative mortality. If concomitant pancreatectomy is anticipated, patients should be selected with extreme caution because long-term survival remains poor.

[Synopsis on clinical practice guideline of gastric cancer in Korea: an evidence-based approach]

Although, gastric cancer is quite common in Korea, the treatment outcome is relatively favorable compared to that of Western countries. However, there is no Korean multidisciplinary guideline for gastric cancer and thus, a guideline adequate for domestic circumstances is required. Experts from related societies developed 22 recommendation statements for the diagnosis (n=9) and treatment (n=13) based on relevant key questions. Evidence levels based on systematic review of literatures were classified as five levels from A to E, and recommendation grades were classified as either strong or weak. The topics of this guideline cover diagnostic modalities (endoscopy, endoscopic ultrasound, radiologic diagnosis), treatment modalities (surgery, therapeutic endoscopy, chemotherapy, radiotherapy) and pathologic evaluation. External review of the guideline was conducted at the finalization phase.

Surgical outcomes and prognostic factors of T4 gastric cancer patients without distant metastasis

Objective

To evaluate surgical outcomes and prognostic factors for T4 gastric cancer treated with curative resection.

Methods

Between January 1994 and December 2008, 94 patients diagnosed with histological T4 gastric carcinoma and treated with curative resection were recruited. Patient characteristics, surgical complications, survival, and prognostic factors were analyzed.

Results

Postoperative morbidity and mortality were 18.1% and 2.1%, respectively. Multivariate analysis indicated lymph node metastasis (hazard ratio, 2.496; 95% confidence interval, 1.218–5.115; p = 0.012) was independent prognostic factor.

Conclusions

For patients with T4 gastric cancer, lymph node metastasis was associated with poorer survival. Neoadjuvant chemotherapy or aggressive adjuvant chemotherapy after radical resection was strongly recommended for these patients.

Clinical practice guidelines for gastric cancer in Korea: an evidence-based approach

Although gastric cancer is quite common in Korea, the treatment outcome is relatively favorable compared to those in western countries. However, there are currently no Korean multidisciplinary guidelines for gastric cancer. Experts from related societies developed guidelines de novo to meet Korean circumstances and requirements, including 23 recommendation statements for diagnosis (n=9) and treatment (n=14) based on relevant key questions. The quality of the evidence was rated according to the GRADE evidence evaluation framework: the evidence levels were based on a systematic review of the literature, and the recommendation grades were classified as either strong or weak. The applicability of the guidelines was considered to meet patients' view and preferences in the context of Korea. The topics of the guidelines cover diagnostic modalities (endoscopy, endoscopic ultrasound, and radiologic diagnosis), treatment modalities (surgery, therapeutic endoscopy, chemotherapy, and radiotherapy), and pathologic evaluation. An external review of the guidelines was conducted during the finalization phase.

Extended multi-organ resection for cT4 gastric carcinoma: A retrospective analysis

Objective: Combined resection for locally advanced (T4) gastric cancer may result in high morbidity and mortality. The aim of this study was to evaluate the clinicopathologic characteristics to determine the prognostic factors for T4 gastric cancers.

Methodology: A total of 463 consecutive patients with gastric cancers were enrolled in this study. Among them, 63 patients received combined resections. Various clinicopathologic factors influencing survival rates were evaluated. Survival rates were calculated according to the Kaplan-Meier method. Prognostic factors were evaluated by the univariate and multivariate analysis.

Results: Thirty-one patients (49.2%) received one additional organ resection and 32 patients (50.8%) received two or more additional organ resections. Curative resection was performed in 49 patients (77.8%). Multivariate analysis identified curative resection (hazard ratio 0.330; 95 percent confidence interval, 0.139-0.784; P = 0.012) and tumor diameter (> 7 cm) (hazard ratio, 3.589; the 95 percent confidence interval, 1.425-9.037; P = 0.007) as independent prognostic factor for patients with T4 gastric cancer undergoing combined resection.

Conclusions: The use of aggressive multi-organ resection was recommended for patients with T4 gastric carcinoma, with tumor diameter as a useful indicator. Patients with relatively small tumor diameter (≤ 7cm) could benefit from multi-organ resections.

Multivisceral resection for gastric cancer: a systematic review

BACKGROUND

The overall prognosis and survival of patients with advanced gastric cancer is generally poor. One of the most powerful predictors of outcomes in gastric cancer surgery is an R0 resection. However, the extent of the required surgical resection and the additional benefit of multivisceral resection (MVR) are controversial.

METHODS

Electronic literature searches were conducted using Medline, EMBASE, and the Cochrane Central Register of Controlled Trials from January 1, 1998 to December 31, 2009. All search titles and abstracts were independently rated for relevance by a minimum of two reviewers.

RESULTS

Seventeen studies were included in this review. Among the 1343 patients who underwent MVR, overall complication rates ranged from 11.8 to 90.5%. Perioperative mortality was found to be 0-15%. Pathological T4 disease was confirmed in 28.8-89% of patients. R0 resection and extent of nodal involvement were important predictors of survival in patients undergoing MVR. Patient outcomes may also be affected by the number of organs resected.

CONCLUSIONS

Gastrectomy with MVR can be safely pursued in patients with locally advanced gastric cancer to achieve an R0 resection. MVR may not be beneficial in patients with extensive nodal disease.

Aggressive surgical approach for patients with T4 gastric carcinoma: promise or myth?

BACKGROUND

Surgical outcomes of multiorgan resection (MOR) for T4 gastric carcinoma reported in the literature are widely variable. We herein report a large surgical series of T4 gastric carcinoma.

METHODS

One hundred seventy-nine patients with cT4 gastric carcinoma were recruited onto the study. Patient characteristics, surgical strategy and related complications, long-term survival, and prognostic factors of T4 gastric carcinoma were analyzed.

RESULTS

Of 179 cT4 gastric carcinoma, there were 57 cT4 (pT3) with MOR, 91 pT4 with MOR, and 31 cT4 without MOR. pT4 with MOR were more likely to be associated with nodal metastasis, cellular dedifferentiation, and lymphoperineural infiltration compared to those of pT0-3 (P < 0.01 for all). For 91 pT4 with MOR, their surgical mortality and morbidity rates were 4.4 and 28.6%, respectively; their 1-, 3-, and 5-year overall survival rates were 55.2, 22.4, and 12.2%, respectively. The long-term survival of cT4 (pT3) with MOR was superior to pT4 with MOR (P = 0.006) and cT4 without MOR (P = 0.004). There was a striking difference between pT4 with MOR, R0 and pT4 with MOR, and R1 or R2 (P = 0.007). By means of multivariate analysis, lymph node status, liver invasion, and positive surgical margin were independent prognostic factors.

CONCLUSIONS

Aggressive surgical management of pT4 gastric carcinoma should be limited to patients without adverse prognostic factors such as advanced nodal involvement and pancreatic invasion.

Surgical outcomes and survival after extended multiorgan resection for T4 gastric cancer

BACKGROUND

Extended multiorgan resection (EMR) for locally advanced (T4) gastric cancer remains controversial. The aim of this study was to evaluate the effectiveness of this approach with regard to morbidity, mortality, and survival.

METHODS

Between 2005 and 2009, 41 patients underwent aggressive surgery for clinical T4 gastric cancer. Univariate and multivariate analyses were used to identify prognostic factors for surgical outcomes and survival in these patients.

RESULTS

Curative resection was performed in 29 patients (70.7%); postoperative morbidity and mortality rates were 17.1% and 4.9%, respectively. The survival rate in R0 resection patients was significantly longer than that in patients undergoing R1 or R2 resection. Multivariate analysis identified resectability and tumor size (≥10 cm) as independent prognostic factor for patients with T4 gastric cancer undergoing combined resection.

CONCLUSIONS

EMR should be performed for patients with T4 gastric cancer in whom curative resection can be used.

Is hypoalbuminemia an independent prognostic factor in patients with gastric cancer?

BACKGROUND

Studies have indicated that hypoalbuminemia is associated with decreased survival of patients with gastric cancer. However, the prognostic value of albumin may be secondary to an ongoing systemic inflammatory response. The aim of the study was to assess the relation between hypoalbuminemia, the systemic inflammatory response, and survival in patients with gastric cancer.

METHODS

Patients diagnosed with gastric carcinoma attending the upper gastrointestinal surgical unit in the Royal Infirmary, Glasgow between April 1997 and December 2005 and who had a pretreatment measurement of albumin and C-reactive protein (CRP) were studied.

RESULTS

Most of the patients had stage III/IV disease and received palliative treatment. The minimum follow-up was 15 months. During follow-up, 157 (72%) patients died of their cancer. On univariate analysis, stage (p < 0.001), treatment (p < 0.001), albumin level (p < 0.001), and CRP level (p < 0.001) were significant predictors of survival. On multivariate analysis, stage (p < 0.001), treatment (p < 0.001), and CRP level (p < 0.001) remained significant predictors of survival. Albumin was no longer an independent predictor of survival.

CONCLUSIONS

Low albumin concentrations are associated with poorer survival in patients with gastric cancer. However, the strength of this relation with survival is dependent on the presence of a systemic inflammatory response, as evidenced by an elevated CRP level. Therefore, it appears that the relation between hypoalbuminemia and poor survival is secondary to that of the systemic inflammatory response.

Appropriate selection of patients for combined organ resection in cases of gastric carcinoma invading adjacent organs

BACKGROUND AND OBJECTIVES

Proper patient selection for multi-organ resection in T4 gastric carcinoma remains controversial. Our aim was to investigate which patients might benefit from multi-organ resection.

METHODS

Among 1,775 consecutive patients receiving gastric cancer surgery, 71 had adjacent organ invasion. Short- and long-term surgical outcomes and associations between clinicopathological factors and overall survival were investigated.

RESULTS

Forty-seven patients underwent curative surgery with multi-organ resection, and 24 underwent non-curative surgery, with or without multi-organ resection. Postoperative morbidity and mortality rates were 31.7% and 3.3%, respectively. Patients receiving curative surgery via multi-organ resection survived longer than those without (MST, 31.5 months vs. 19.1 months, P = 0.046). Multi-organ resection did not affect survival when performed in non-curative surgery. N3 lymph node metastasis was an independent prognostic factor for poor outcome (HR = 3.89, 95% CI = 1.40-10.83) in curatively resected patients; patients with N3 lymph node metastasis showed similar survival to patients receiving non-curative surgery.

CONCLUSION

Multi-organ resection should be performed only when no incurable factors are present, and R0 resection is most likely. Multi-organ organ resection does not, however, seem to be effective in patients with N3 lymph node metastasis, even when curative resection is performed.