Morbidity, mortality, and pathological response in patients with gastric cancer preoperatively treated with chemotherapy or chemoradiotherapy

Postoperative Complications After Neoadjuvant Chemotherapy Versus Upfront Surgery in Gastric Adenocarcinoma: A Population-Based Nationwide Study in Finland

BACKGROUND

To date, no large population-based studies have compared complications and short-term outcomes between neoadjuvant chemotherapy and upfront surgery in gastric cancer. More nationwide studies with standardized reporting on complications are needed to enable international comparison between studies. This study aimed to compare postoperative complications between neoadjuvant therapy and upfront surgery after gastrectomy for gastric adenocarcinoma in a population-based setting.

METHODS

This population-based study based on the Finnish National Esophago-Gastric Cancer Cohort included all patients 18 years of age or older undergoing gastrectomy for gastric adenocarcinoma in Finland during 2005-2016. Logistic regression provided odds ratios (ORs) with 95% confidence intervals (CIs), both crude and adjusted for key confounders. Different types of complications were graded based on the Esophagectomy Complications Consensus Group definitions, and major complications were assessed by the Clavien-Dindo scale.

RESULTS

This study analyzed 769 patients. Neoadjuvant chemotherapy did not increase major postoperative complications after gastrectomy for gastric cancer compared with upfront surgery (OR, 1.12; 95% CI 0.81-1.56). Furthermore, it did not increase pneumonia, anastomotic complications, wound complications, or other complications.

CONCLUSIONS

Neoadjuvant therapy is not associated with increased postoperative complications, reoperations, or short-term mortality compared with upfront surgery in gastric adenocarcinoma.

Effect of neoadjuvant treatment combined with radical gastrectomy on postoperative complications and prognosis of gastric cancer patients

OBJECTIVE

To investigate the occurrence of postoperative complications in and factors influencing the prognosis of patients undergoing radical gastrectomy after neoadjuvant chemotherapy.

METHODS

A total of 238 patients with gastric cancer were enrolled in this study. There were 194 patients who underwent neoadjuvant chemotherapy before surgery and 44 patients who underwent concurrent radiochemotherapy before surgery. The clinical data of patients and the incidence of postoperative complications were collected. Postoperative complications were graded based on the Clavien-Dindo classification. The impact of postoperative complications on the prognosis of patients was analysed.

RESULTS

(1) The overall incidence of postoperative complications was 17.2% (41/238) among all patients. A total of 49 patients experienced postoperative complications, including 12 cases of grade I, 15 cases of grade II, seven cases of grade IIIa, three cases of grade IIIb, seven cases of grade IV, and four cases of grade V complications. A total of 21 patients experienced severe complications. Multivariate analysis indicated that age, body mass index (BMI), and scope of gastrectomy were independent risk factors for postoperative complications (p < .05). (2) The five-year survival rate for the entire group of patients was 58.4%. The five-year survival rate for the complication group and non-complication group were 31.7% and 51.7%, respectively, with a significant difference between the two groups (χ²=15.41p = .000). Based on the severity of complications, the subgroup analysis indicated that the five-year survival rate for patients with severe postoperative complications was 21.1% and that for patients with non-severe complications was 40.9%; the difference was significant (χ²=21.70, p = .000). (3) Multivariate analysis indicated that age, pathological tumour, node, and metastasis (ypTNM) stages II-III, operation time >3.5 h, total gastrectomy, and postoperative complications were independent risk factors affecting the prognosis of patients undergoing radical gastrectomy after neoadjuvant chemotherapy. Postoperative adjuvant therapy was an independent protective factor for patient prognosis (p < .05).

CONCLUSION

The incidence of complications in patients undergoing radical gastrectomy after neoadjuvant chemotherapy is closely correlated with patient age and the scope of surgical resection, and the occurrence of severe complications has a significant adverse effect on patient prognosis.

Neoadjuvant chemoradiotherapy plus postoperative adjuvant XELOX chemotherapy versus postoperative adjuvant chemotherapy with XELOX regimen for local advanced gastric cancer-A randomized, controlled study

OBJECTIVE

The aim of this study was to compare the clinical efficacy of neoadjuvant chemoradiotherapy (NACRT) combined with postoperative adjuvant XELOX (Oxaliplatin +Capecitabine) chemotherapy and postoperative adjuvant chemotherapy (ACT) with XELOX for local advanced gastric cancer (LAGC).

METHODS

In this prospectively randomized trial, we investigated the effect of NACRT combined with postoperative ACT for LAGC. 60 patients were randomly divided into NACRT group and ACT group, with 30 patients in each group. Patients in NACRT group were given three-dimensional conformal radiotherapy (45 Gy/1.8 Gy/f) accompanied by synchronous XELOX of two cycles, followed by surgery, and then postoperative adjuvant XELOX chemotherapy of four cycles was performed. Patients in ACT group received surgery in advance, and then XELOX chemotherapy of six cycles was given.

RESULTS

The objective response rate of NACRT was 76.7%. The overall incidence of postoperative complications in NACRT group was not significantly different from that in ACT group (23.1% vs 30.0%, p = 0.560). The 1 year, 2 years, and 3 years progression-free survival (PFS）and overall survival (OS) in NACRT and ACT groups were 80.0% vs 56.7%, 73.3% vs 46.7%, 60.0% vs 33.3%, and 86.7% vs 80.0%, 76.7% vs 66.7%, 63.3% vs 50.0%, respectively. Patients in NACRT group showed a significantly higher R0 resection rate (84.6% vs 56.7%, p = 0.029),lower loco-regional recurrence rate (36.7% vs 11.5%, p = 0.039), longer PFS (p = 0.019) and freedom from locoregional progression(FFLP) (p = 0.004) than patients in ACT group, while there was no difference in OS (p = 0.215) and in toxicity incidence (p > 0.05).

CONCLUSIONS

NACRT combined with postoperative adjuvant XELOX chemotherapy can improve R0 resection rate, reduce loco-regional recurrence, prolong PFS and FFLP without increasing the incidence of postoperative complications in patients with LAGC.

ADVANCES IN KNOWLEDGE

Compared with postoperative adjuvant chemotherapy, locally advanced gastric cancer patients may benefit from neoadjuvant chemoradiotherapy, and toxicity associated with chemoradiotherapy was tolerant and manageable.

Neoadjuvant chemoradiotherapy followed by laparoscopic distal gastrectomy in advanced gastric cancer: A case report and review of literature

BACKGROUND

The laparoscopic technique has been widely applied for early gastric cancer, with the advantages of minimal invasion and quick recovery. However, there is no report about the safety and oncological outcome of laparoscopic gastrectomy with D2 lymph node dissection for patients after neoadjuvant chemoradiotherapy.

CASE SUMMARY

A 60-year-old man was diagnosed with advanced distal gastric cancer, cT4aN1M0 stage III. The neoadjuvant chemoradiotherapy was performed based on the regimen of gross tumor volume 50G y/25 f and clinical target volume 45 Gy/25 f, as well as concurrent S-1 60 mg Bid. Then laparoscopic distal gastrectomy with D2 lymph node dissection was undertaken successfully for him after achieving partial response evaluated by radiological examination. The patient recovered smoothly without moderate or severe postoperative complications. The postoperative pathological stage was ypT3N0M0 with American Joint Committee on Cancer tumor regression grade 1. He was still in good condition after 5 years of follow-up.

CONCLUSION

Neoadjuvant chemoradiotherapy followed by laparoscopic technique could be applicable and may achieve satisfactory oncological outcomes. Our finding requires further validation by cohort studies.

Prognostic Significance of Complete Pathologic Response Obtained with Chemotherapy Versus Chemoradiotherapy in Gastric Cancer

BACKGROUND

Few studies have compared the survival advantage of complete pathologic response (cPR) achieved through neoadjuvant chemotherapy (nCT) versus neoadjuvant chemoradiotherapy (nCRT) in gastric adenocarcinoma. Our study utilizes a large national cancer database to address this question.

PATIENTS AND METHODS

This is a retrospective review of patients with clinical stage I to III gastric adenocarcinoma from 2004 to 2013 who received nCT or nCRT. Patients who achieved cPR were selected. Associations were evaluated using Mann-Whitney U and Fisher's exact tests. Survival information was summarized using standard Kaplan-Meier methods, where estimates of the median and 5-year survival rates were estimated with 95% confidence intervals.

RESULTS

A total of 413 patients who had cPR were identified. Eighty-four patients received nCT and 329 patients received nCRT. Patients in the nCRT group had higher clinical stage (88.4% vs. 75.0%) and more proximal location of tumors (95.4% vs. 45.2%). The nCT group (n = 84) had a 94% 5-year survival rate, while the nCRT group's (n = 329) rate was 60% (p < 0.001). On Cox regression modeling using a propensity-weighted approach, nCT treatment was an independent predictor of improved overall survival (nCRT vs. nCT; HR 10.44, p < 0.001).

CONCLUSIONS

The use of nCT leads to a significant increase in overall survival in patients when compared with nCRT for those who achieved cPR in gastric adenocarcinoma. While this study is limited in identifying the cause for this difference in overall survival, this important finding nonetheless requires further investigation and should be considered in the development of future gastric cancer trials.

Impact of neoadjuvant chemotherapy on surgical and pathological results of gastric cancer patients: A case-control study

BACKGROUND AND OBJECTIVE

Neoadjuvant chemotherapy (NACT) followed by radical surgery represents a treatment option for patients with advanced gastric cancer (GC). This case-control study aimed to evaluate the clinicopathological characteristics and surgical outcomes of GC patients who received NACT, and its impact on survival.

METHODS

We retrospectively reviewed all patients with GC who underwent gastrectomy. A total of 45 cases with NACT were matched with consecutive 45 patients who underwent upfront gastrectomy for the following characteristics: gender, age, gastrectomy type, lymphadenectomy extent, American Society of Anesthesiologists class, histological type, cT and cN.

RESULTS

NACT group had smaller tumors (4.9 vs 6.8 cm P = .006), lower lymphatic invasion rate (40% vs 73.3%, P = .001), lower venous invasion rate (18% vs 46.7%, P = .003) and lower perineural invasion rate (35% vs 77.8%, P < .0001). The ypTNM stage was lower in patients treated with NACT (P < .001). The major postoperative complication (POC) rate was lower in NACT patients (6.7% vs 24.4%, P = .02), as was hospital length of stay (10.8 vs 17 days, P = .005).

CONCLUSIONS

NACT allowed nodal and tumor downstaging. In addition, patients who underwent NACT had fewer POC and shorter length of hospital stay.

Pathological response measured using virtual microscopic slides for gastric cancer patients who underwent neoadjuvant chemotherapy

BACKGROUND

Although pathological response is a common endpoint used to assess the efficacy of neoadjuvant chemotherapy (NAC) for gastric cancer, the problem of a low rate of concordance from evaluations among pathologists remains unresolved. Moreover, there is no globally accepted consensus regarding the optimal evaluation. A previous study based on a clinical trial suggested that pathological response measured using digitally captured virtual microscopic slides predicted patients’ survival well. However, the pathological concordance rate of this approach and its usefulness in clinical practice were unknown.

AIM

To investigate the prognostic utility of pathological response measured using digital microscopic slides in clinical practice.

METHODS

We retrospectively evaluated pathological specimens of gastric cancer patients who underwent NAC followed by surgery and achieved R0 resection between March 2009 and May 2015. Residual tumor area and primary tumor beds were measured in one captured image slide, which contained the largest diameter of the resected specimens. We classified patients with < 10% residual tumor relative to the primary tumorous area as responders, and the rest as non-responders; we then compared overall survival (OS) and relapse-free survival (RFS) between these two groups. Next, we compared the prognostic utility of this method using conventional Japanese criteria.

RESULTS

Fifty-four patients were evaluated. The concordance rate between two evaluators was 96.2%. Median RFS of 25 responders and 29 non-responders was not reached (NR) vs 18.2 mo [hazard ratio (HR) = 0.35, P = 0.023], and median OS was NR vs 40.7 mo (HR = 0.3, P = 0.016), respectively. This prognostic value was statistically significant even after adjustment for age, eastern cooperative oncology group performance status, macroscopic type, reason for NAC, and T- and N-classification (HR = 0.23, P = 0.018). This result was also observed even in subgroup analyses for different macroscopic types (Borrmann type 4/non-type 4) and histological types (differentiated/undifferentiated). Moreover, the adjusted HR for OS between responders and non-responders was lower in this method than that in the conventional histological evaluation of Japanese Classification of Gastric Carcinoma criteria (0.23 vs 0.39, respectively).

CONCLUSION

The measurement of pathological response using digitally captured virtual microscopic slides may be useful in clinical practice.

Postoperative morbidity and mortality after neoadjuvant chemotherapy versus upfront surgery for locally advanced gastric cancer: a propensity score matching analysis

Background

Cohort studies have shown that neoadjuvant chemotherapy (NAC) is not associated with increased risk of postoperative complications and mortality as compared to upfront surgery (SURG).

Objective

The aim of this study was to compare postoperative morbidity and mortality after NAC with SURG.

Patients and methods

Patients who underwent gastrectomy with D2 lymphadenectomy for advanced gastric cancer (GC) between 2010 and 2017 were selected. The impact of neoadjuvant chemotherapy on surgical safety was investigated by using propensity score matching.

Results

Three hundred and seventy-seven patients were included. After propensity score matching, 86 patients in each group were matched. The percentage of patients with one or more complications was 10.5% in NAC group and 15.1% in SURG group (P=0.361), there was no mortality developed in either group. The total blood loss was significantly more in the NAC group than that in the SURG group (320.79 vs 243.37 ml, P<0.04). In univariate and multivariate of the matched cohort, sex, age (<70), BMI (<24), ASA grade, surgical procedure (open vs laparoscopy), gastrectomy extent, cTNM and Charlson index comorbidity were not associated with postoperative complications (all P>0.05).

Conclusion

This study showed that postoperative morbidity and mortality were similar for NAC group and SURG group.

The Impact of Positive Margins on Outcome Among Patients With Gastric Cancer Treated With Radiation

OBJECTIVES

Positive surgical margins have been associated with worse outcomes in gastric cancer patients. We evaluated the impact of positive margins in a modern cohort treated with radiotherapy.

METHODS

We performed a multi-institutional retrospective analysis of patients treated from 1998 through 2010. All underwent definitive surgery and were followed up for recurrence and survival. We assessed associations with positive margins using the log-rank tests and Cox proportional hazard models.

RESULTS

We identified 91 patients with a median follow-up of 42 months. Seven received radiation before surgery; the remainder were treated postoperatively. Epirubicin-based chemotherapy was given to 8 patients perioperatively and 25 postoperatively. Nineteen had positive margins (21%), including 25% of patients who received chemotherapy perioperatively. All patients who received neoadjuvant radiotherapy had negative margins. There were 41 recurrences and 44 deaths. Positive margins were associated with increased recurrence risk after adjusting for other factors (hazard ratio=2.8, P=0.01). In addition, median survival with positive margins was 31 months as compared with 77 months after complete resection (P=0.13).

CONCLUSIONS

Positive margins were associated with recurrence despite aggressive multimodality therapy including radiotherapy and the selective use of chemotherapy. Thus, additional consideration is warranted for strategies such as neoadjuvant chemoradiation intended to facilitate complete resection.

The impact of neoadjuvant therapy for gastroesophageal adenocarcinoma on postoperative morbidity and mortality

BACKGROUND AND OBJECTIVES

We sought to study the impact of neoadjuvant therapy (NAT) on postoperative complications following surgical resection of adenocarcinomas of the stomach and gastroesophageal junction (GEJ).

METHODS

We compared the postoperative outcomes of 308 patients undergoing a surgery-first approach and 145 patients undergoing NAT followed by curative-intent surgery for adenocarcinomas of the stomach and GEJ from 1995-2014.

RESULTS

Patients receiving NAT were more likely to be younger, have tumors of the GEJ, to undergo esophagogastrectomy and D2 lymphadenectomy, and to have more advanced stage disease than patients undergoing surgery first. There were no differences in overall 30-day morbidity or mortality rates between the groups, yet patients undergoing surgery first were more likely to have higher-grade complications than those undergoing NAT. Age >65 years, higher ASA score, concomitant splenectomy, more advanced tumor stage, and year of surgery were independent risk factors for postoperative morbidity, but receipt of NAT was not an independent predictor of postoperative morbidity.

CONCLUSIONS

Despite having more advanced disease and undergoing higher-risk surgical procedures, patients with adenocarcinomas of the stomach or GEJ who receive NAT prior to surgery are no more likely to suffer postoperative complications than patients treated with a surgery-first approach. J. Surg. Oncol. 2016;113:560-564. © 2016 Wiley Periodicals, Inc.

Adjuvant Therapy Completion Rates in Patients with Gastric Cancer Undergoing Perioperative Chemotherapy Versus a Surgery-First Approach

Delayed recovery after gastrectomy may preclude the administration of adjuvant therapy in a significant percentage of patients who undergo elective gastrectomy as the initial therapy for gastric cancer. Clinicopathologic and treatment variables of 155 patients undergoing potentially curative gastrectomy for stages Ib-IIIc gastric adenocarcinoma from 2001 to 2014 were analyzed, and rates of receipt of chemotherapy and radiotherapy in patients treated with either a surgery-first approach (SURG) or neoadjuvant therapy followed by surgery followed by postoperative therapy (PERIOP) were compared. SURG patients (n = 93) were older and more likely to have distal tumors and to undergo distal gastrectomy and D1 lymphadenectomy than PERIOP patients (n = 62). The distribution of ASA scores was similar between groups. SURG patients were less likely than PERIOP patients to complete at least one cycle of chemotherapy (56 vs 100%, P = 0.001) and all recommended chemotherapy and radiation therapy (44 vs 66%, P = 0.013). These findings were consistent for SURG patients treated during different time periods throughout the study and for patients of poorer performance status. A significantly higher percentage of gastric cancer patients treated with perioperative chemotherapy receive some or all of the recommended components of multimodality therapy than patients treated with a surgery-first approach.

Determination of the optimal cutoff percentage of residual tumors to define the pathological response rate for gastric cancer treated with preoperative therapy (JCOG1004-A)

BACKGROUND

Pathological response rate (pathRR) is a common endpoint used to assess the efficacy of preoperative therapy for gastric cancer. PathRR is estimated based on the percentage of the residual tumor area in the primary tumorous bed. Various cutoff definitions used in previous trials (e.g., 10, 33, 40, 50, 67 %) often impair the comparability of pathRRs between trials.

METHODS

Individual patient data were used from four JCOG trials evaluating preoperative chemotherapy (JCOG0001, JCOG0002, JCOG0210, JCOG0405). Pathological specimens were evaluated from 173 out of 188 patients (92 %) who underwent surgery. Residual tumor area and primary tumorous beds were traced on a virtual microscopic slide by one pathologist and another confirmed these areas. The hazard ratio (HR) in overall survival was calculated for each cutoff percentage by stratified Cox regression analysis, including the study as a stratification factor, and concordance probability estimates (CPE) were calculated.

RESULTS

The numbers of patients with 0%, 1-10 %, 11-33 %, 34-50 %, 51-66 %, and 67-100 % residual tumors were 8, 35, 33, 27, 23, and 47, respectively. HRs in 10, 33, 50, and 67 % cutoffs were 1.91, 1.70, 1.55, and 1.71 for the overall population, and CPEs were 0.56, 0.56, 0.55, and 0.55, respectively. In patients with R0 resection, HRs in 10, 33, 50, and 67 % cutoffs were 1.87, 1.54, 1.24, and 1.38, and CPEs were 0.56, 0.55, 0.52, and 0.52. In subgroup analyses, the 10 % cutoff did not predict survival well for type 4 (linitis plastica) tumors.

CONCLUSIONS

The 10 % cutoff should be the global standard cutoff of %residual tumor to determine pathRR. PathRR might not be recommended for clinical trials where the main subjects are type 4 tumors.

Preoperative treatment with radiochemotherapy for locally advanced gastroesophageal junction cancer and unresectable locally advanced gastric cancer

Background.

To purpose of the study was to analyze the results of preoperative radiochemotherapy in patients with unresectable gastric or locoregionally advanced gastroesophageal junction (GEJ) cancer treated at a single institution.

Patients and methods.

Between 1/2004 and 6/2012, 90 patients with locoregionally advanced GEJ or unresectable gastric cancer were treated with preoperative radiochemotherapy at the Institute of Oncology Ljubljana. Planned treatment schedule consisted of induction chemotherapy with 5-fluorouracil and cisplatin, followed by concomitant radiochemotherapy four weeks later. Three-dimensional conformal external beam radiotherapy was delivered by dual energy (6 and 15 MV) linear accelerator in 25 daily fractions of 1.8 Gy in 5 weeks with two additional cycles of chemotherapy repeated every 28 days. Surgery was performed 4–6 weeks after completing radiochemotherapy. Following the surgery, multidisciplinary advisory team reassessed patients for the need of adjuvant chemotherapy. The primary endpoints were histopathological R0 resection rate and pathological response rate. The secondary endpoints were toxicity of preoperative radiochemotherapy and survival.

Results.

Treatment with preoperative radiochemotherapy was completed according to the protocol in 84 of 90 patients (93.3%). Twenty patients (22.2%) did not undergo the surgery because of the disease progression, serious comorbidity, poor performance status or still unresectable tumour. In 13 patients (14.4%) only exploration was performed because the tumour was assessed as unresectable or diffuse peritoneal carcinomatosis was established. Fifty-seven patients (63.4%) underwent surgery with the aim of complete removal of the tumour. Radical resection was achieved in 50 (55.6%) patients and the remaining seven (7.8%) patients underwent non-radical surgery (R1 in five and R2 in two patients). In this group of patients (n = 57), pathological complete response of tumour was achieved in five patients (5.6% of all treated patients or 8.8% of all operated patients). Down-staging was recorded in 49 patients (86%), in one patient (1.8%) the stage after radiochemotherapy was unchanged while in seven patients (12.3%) the pathological stage was higher than clinical, mainly due to higher pN stage. No death was recorded during preoperative radiochemotherapy. Most grade 3 and 4 toxicities were due to vomiting, nausea and bone marrow suppression (granulocytopenia). Twenty-six (45.6%) patients died due to GEJ or gastric carcinoma, one died because of septic shock following the surgery and a reason for two deaths was unknown. Twenty-eight patients (49.1%) were disease free at the time of analysis, while 29 patients (50.9%) developed the recurrence, mostly as distant metastases. At two years, locoregional control, disease-free survival, disease-specific survival and overall survival were 82.9%, 43.9%, 56.9% and 53.9%, respectively.

Conclusions.

Preoperative radiochemotherapy was feasible in our group of patients and had acceptable toxicity. Majority of patients achieved down-staging, allowing greater proportion of radical resections (R0), which are essential for patients’ cure.

Neoadjuvant chemoradiotherapy followed by D2 gastrectomy in locally advanced gastric cancer

AIM: To investigate the efficacy of neoadjuvant chemoradiotherapy (NACRT) for resectability of locally advanced gastric cancer (LAGC).

METHODS: Between November 2007 and January 2014, 29 patients with LAGC (clinically T3 with distal esophagus invasion/T4 or bulky regional node metastasis) that were treated with NACRT followed by D2 gastrectomy were included in this study. Resectability was evaluated with radiologic and endoscopic exams before and after NACRT. Using three-dimensional conformal radiotherapy, patients received 45 Gy, with a daily dose of 1.8 Gy. The entire tumor extent and the regional metastatic lymph nodes were included in the gross tumor volume. Patients presenting with a resectable tumor after NACRT received a total or subtotal gastrectomy with D2 dissection. The pathologic tumor response was evaluated using Japanese Gastric Cancer Association histologic evaluation criteria. Postoperative morbidity was evaluated using the National Cancer Institute-Common Terminology Criteria for Adverse Events version 4.0. Overall survival (OS) and progression-free survival (PFS) rates were estimated using a Kaplan-Meier analysis and compared using the log-rank test.

RESULTS: All patients were assessed as unresectable cases. Twenty-four patients (24/29; 82.8%) showed LAGC on positron emission tomography-computed tomography (CT) and contrast-enhanced CT, whereas four patients (4/29; 13.8%) with vague invasion or abutment to an adjacent organ underwent diagnostic laparoscopy. One patient (1/29; 3.4%), initially assessed as a resectable case, underwent an “open and closure” after the tumor was found to be unresectable. Abutment to an adjacent organ (34.5%) was the most common reason for NACRT. The clinical response rate one month after NACRT was 44.8%. After NACRT, 69% (20/29) of patients had a resectable tumor. Of the 20 patients with a resectable tumor, 18 patients (62.1%) underwent a D2 gastrectomy. The R0 resection rate was 94.4% and two patients (2/18; 11.1%) showed a complete response. The median follow-up duration was 13.5 mo. The one-year OS and PFS rates were 72.4 and 48.9%, respectively. The one-year OS, PFS, local failure-free survival, and distant metastasis-free survival were higher in patients with a resectable tumor after NACRT (P < 0.001, P < 0.001, P < 0.001, and P = 0.078, respectively). No grade 3-4 late treatment-related toxicities or postoperative mortalities were observed.

CONCLUSION: NACRT with D2 gastrectomy showed a high rate of R0 resection and promising local control, which may increase the R0 resection opportunity resulting in survival benefit.

High-Grade Toxicity to Neoadjuvant Treatment for Upper Gastrointestinal Carcinomas: What is the Impact on Perioperative and Oncologic Outcomes?

BACKGROUND

Perioperative oncologic treatments provide a survival benefit for junctional and gastric adenocarcinoma (JGA) and esophageal cancer (EC). Whether neoadjuvant therapy toxicity (NTT) correlates with increased perioperative risk remains unclear. We aimed to evaluate the impact of grade III/IV NTT on postoperative and oncologic outcomes in resected upper gastrointestinal malignancies.

METHODS

A multicenter retrospective analysis was performed on consecutive patients who benefited from neoadjuvant chemo(radio)therapy followed by surgery between 1997 and 2010 for JGA (first cohort, n = 653) and for EC (second cohort, n = 640). Data between patients who experienced NTT were compared to those who did not.

RESULTS

NTT was associated with higher postoperative mortality after resection of JGA (P = 0.001) and after esophagectomy (P < 0.001), more non-R0 resections (JGA P = 0.019, EC P = 0.024), a decreased administration of adjuvant treatment among the JGA cohort (P = 0.012), and higher surgical morbidity (JGA P = 0.005, EC P = 0.020). Median survival was reduced in patients who experienced NTT in both cohorts (JGA P = 0.018, EC P = 0.037). After adjustment on confounding variables, NTT was independently associated with postoperative mortality in both cohorts (P ≤ 0.007).

CONCLUSIONS

NTT is a predictor of postoperative mortality, correlates with higher postoperative morbidity, and negatively affects oncologic outcomes for upper gastrointestinal carcinomas.

WITHDRAWN: Clinical effectiveness of neoadjuvant chemotherapy in advanced gastric cancer: An updated meta-analysis of 12 randomized controlled trials

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Effect of neoadjuvant chemotherapy on postoperative morbidity and mortality in patients with locally advanced gastric cancer

BACKGROUND

Neoadjuvant chemotherapy has been shown to improve the rate of complete (R0) resection and downstaging in patients with localized gastric cancer. There are few reports, however, regarding its impact on postoperative morbidity and mortality. The aims of this study were to analyse complication and mortality rates after neoadjuvant chemotherapy using a modified regimen of folinic acid, 5-fluorouracil and oxaliplatin (mFOLFOX6) for locally advanced gastric cancer (AGC), compared with rates in patients who underwent surgery without neoadjuvant chemotherapy.

METHODS

Data were collected from patients with AGC enrolled in a phase II trial of four cycles of neoadjuvant mFOLFOX6 followed by surgery, between January 2005 and June 2008 at two of three institutions, and compared with those from a cohort of patients with AGC who underwent surgery alone at one of the institutions in 2006.

RESULTS

Among 51 patients who received neoadjuvant chemotherapy, there were no deaths and a morbidity rate of 24 per cent after surgery. Comparison of 48 patients in one institution who received neoadjuvant chemotherapy with 92 patients who had surgery alone in the same institution showed no increase in postoperative morbidity (23 versus 29 per cent; P = 0·417). Combined resection was the only risk factor for postoperative morbidity after neoadjuvant chemotherapy.

CONCLUSION

Neoadjuvant chemotherapy with mFOLFOX is a safe treatment for patients with localized AGC, and does not increase postoperative morbidity or mortality.

Effect of complication grade on survival following curative gastrectomy for carcinoma

AIM: To elucidate the potential impact of the grade of complications on long-term survival of gastric cancer patients after curative surgery.

METHODS: A total of 751 gastric cancer patients who underwent curative gastrectomy between January 2002 and December 2006 in our center were enrolled in this study. Patients were divided into four groups: no complications, Grade I, Grade II and Grade III complications, according to the following classification systems: T92 (Toronto 1992 or Clavien), Accordion Classification, and Revised Accordion Classification. Clinicopathological features were compared among the four groups and potential prognostic factors were analyzed. The Log-rank test was used to assess statistical differences between the groups. Independent prognostic factors were identified using the Cox proportional hazards regression model. Stratified analysis was used to investigate the impact of complications of each grade on survival.

RESULTS: Significant differences were found among the four groups in age, sex, other diseases (including hypertension, diabetes and chronic obstructive pulmonary disease), body mass index (BMI), intraoperative blood loss, tumor location, extranodal metastasis, lymph node metastasis, tumor-node-metastasis (TNM) stage, and chemotherapy. Overall survival (OS) was significantly influenced by the complication grade. The 5-year OS rates were 43.0%, 42.5%, 25.5% and 9.6% for no complications, and Grade I, Grade II and Grade III complications, respectively (P < 0.001). Age, tumor size, intraoperative blood loss, lymph node metastasis, TNM stage and complication grade were independent prognostic factors in multivariate analysis. With stratified analysis, lymph node metastasis, tumor size, and intraoperative blood loss were independent prognostic factors for Grade I complications (P < 0.001, P = 0.031, P = 0.030). Age and lymph node metastasis were found to be independent prognostic factors for OS of gastric cancer patients with Grade II complications (P = 0.034, P = 0.001). Intraoperative blood loss, TNM stage, and chemotherapy were independent prognostic factors for OS of gastric cancer patients with Grade III complications (P = 0.003, P = 0.005, P < 0.001). There were significant differences among patients with Grade I, Grade II and Grade III complications in TNM stage II and III cancer (P < 0.001, P = 0.001).

CONCLUSION: Complication grade may be an independent prognostic factor for gastric cancer following curative resection. Treatment of complications can improve the long-term outcome of gastric cancer patients.

The has-miR-526b binding-site rs8506G>a polymorphism in the lincRNA-NR_024015 exon identified by GWASs predispose to non-cardia gastric cancer risk

Gastric cancer including the cardia and non-cardia types is the second frequent cause of cancer-related deaths worldwide. A subset of non-cardia gastric cancer genetic susceptibility loci have been addressed among Asian through genome-wide association studies (GWASs). This study was to evaluate the effects of single nucleotide polymorphisms (SNPs) of long intergenic non-coding RNAs (lincRNAs) on non-cardia gastric cancer susceptibility in Chinese populations. We selected long intergenic noncoding RNAs (lincRNAs) located in non-cardia gastric cancer risk-related loci and identified 10 SNPs located within lincRNA exonic regions. We examined whether genetic polymorphisms in lincRNAs exons are associated with non-cardia gastric cancer risk in 438 non-cardia gastric cancer patients and 727 control subjects in Chinese populations using logistic regression. Functional relevance was further examined by biochemical assays. We found that lincRNA-NR_024015 rs8506AA carrier was significantly associated with risk of non-cardia gastric cancer (adjusted odds ratio [OR] = 1.56, 95%CI = 1.03–2.39, compared with the rs8506 AG or GG genotype. Further stratification analysis showed that the risk effect was more pronounced in subgroups of smokers (P = 0.001). Biochemical analysis demonstrated that the G to A base change at rs8506G>A disrupts the binding site for has-miR-526b, thereby influencing the transcriptional activity of lincRNA-NR_024015 and affecting cell proliferation. Our present study established a robust association between the rs8506G>A polymorphism in the lincRNA-NR_024015 exon and the risk of non-cardia gastric cancer.

Clinical effectiveness of neoadjuvant chemotherapy in advanced gastric cancer: an updated meta-analysis of randomized controlled trials

AIMS

To assess the efficacy and safety of neoadjuvant chemotherapy (NAC) for advanced gastric cancer (AGC).

METHODS

By searching electronic databases (PubMed, Embase, Cochrane Library) and ASCO proceedings from 1990 to 2012, all randomized controlled trials (RCTs) which compared the effect of NAC-combined surgery versus surgery alone in AGC were included. All calculations and statistical tests were performed using RevMan 5.0 software.

RESULTS

12 RCTs with a total of 1820 patients were included. All patients had locally advanced but resectable gastric cancer and received NAC. NAC can slightly improve the survival rate (OR = 1.32, 95% confidence interval (CI): 1.07-1.64, P = 0.01), with little or no significant benefits in subgroup analyses between either different population or regimens. NAC can significantly improve the 3-year progression-free survival (PFS) (OR: 1.85, 95% CI: 1.39-2.46, p < 0.0001), tumor down-staging rate (OR: 1.71, 95% CI: 1.26, 2.33, p = 0.0006) and R0 resection rate (OR: 1.38, 95% CI: 1.08-1.78, P = 0.01) of patients with AGC. There was no difference between the two arms, in terms of relapse rates (OR: 1.03, 95% CI: 0.60-1.78, p = 0.92), operative complications (OR: 1.20, 95% CI: 0.90-1.58, p = 0.21), perioperative mortality (OR: 1.14, 95% CI: 0.64-2.05, p = 0.65) and grade 3/4 adverse effects: gastrointestinal problem (OR: 0.57, 95% CI: 0.25-1.30, p = 0.18), leukopenia (OR: 0.88, 95% CI: 0.41-1.91, p = 0.75), thrombocytopenia (OR: 1.27, 95% CI: 0.27-5.93, p = 0.76).

CONCLUSION

NAC is effective and safe. However, further prospective multi-national and multi-center RCTs are still needed in order to investigate the long-term oncological and functional outcomes to define the clinical benefits of NAC and the most effective strategies for AGC.

Feasibility of preoperative and postoperative chemoradiotherapy in gastric adenocarcinoma. Two phase II studies done in parallel. Fédération Francophone de Cancérologie Digestive 0308

BACKGROUND

For resectable gastric cancer, both postoperative chemoradiotherapy and perioperative chemotherapy demonstrate high-level evidence for improved survival in Western populations. To evaluate the feasibility of pre- or postoperative chemoradiotherapy, we proposed two multicentre phase II studies.

PATIENTS AND METHODS

Patients with localised, histologically confirmed gastric cancer and Eastern Cooperative Oncology Group (ECOG) performance status <2 judged suitable for curative resection were eligible. Eligible patients were assigned to either preoperative chemoradiotherapy followed by surgical resection or surgical resection followed by chemoradiotherapy depending on each centre. Chemoradiotherapy regimen included four courses of FOLFIRI (5 Fluorouracil, Leucovorin, Irinotecan) regimen then Concurrent fluorouracil at 200 mg/m2/d by continuous infusion 5 days each week. A dose of 50 Gy in 25 fractions in the preoperative study, or 45 Gy in 25 fractions in the postoperative study, was delivered. The primary end-point for both studies was the proportion of patients, who completed the therapeutic sequence.

RESULTS

Between September 2007 and January 2010, 63 patients were included in both studies. The postoperative study was stopped for futility at the first step. In the preoperative study, 31 patients (73.8%, confidence interval (CI) 95%: 65.8-90.1%) received complete therapeutic sequence. Serum albumin and dietary restriction evaluated by QLQ-STO22 (Quality of Life-Stomach module) score were significantly linked with chemoradiotherapy feasibility in univariate analysis with respectively Odds-ratio (OR) 1.16 [CI 95%: 1.01-1.33] and 0.17 [0.03-0.89], p=0.04. Median overall survival time was 26.4 months in the preoperative study.

CONCLUSION

Feasibility of chemoradiotherapy was not achieved for these studies: 73.8% (CI 95%: 65.8-90.1) and 42.9% (CI 95%: 21.8-66%) in preoperative and postoperative settings respectively.

Positive association between Toll-like receptor 4 gene +896A/G polymorphism and susceptibility to gastric carcinogenesis: a meta-analysis

Several studies have investigated the association between the Toll-like receptor 4 (TLR4) gene +896A/G polymorphism and gastric carcinogenesis, including gastric cancer and precancerous gastric lesions. However, published results are inconsistent. So, we performed a meta-analysis to assess whether the TLR4 +896A/G single-nucleotide polymorphism (SNP) is a risk factor in gastric cancer development. We searched PubMed and Embase databases for studies that reported the odds ratio (OR) and 95 % confidence interval (CI) for the association between the TLR4 +896A/G SNP and the risk of gastric cancer and/or precancerous lesions with the last update of November 2012. Data were analyzed using Review Manager (Version 5.1), and publication bias was estimated. We included 10 study populations, comprising 2,233 cases and 2,849 controls from 8 publications. The pooled OR was 2.00 (95 % CI = 1.59-2.53) for the G allelic model. Analysis stratified by different stages and anatomic sites of neoplasia resulted in a significantly increased risk associated with gastric cancer (OR = 1.87, 95 % CI = 1.44-2.44), especially the non-cardia subtype (OR = 2.03, 95 % CI = 1.51-2.72). Besides, the G allele emerged as a strong risk factor for precancerous gastric lesions (OR = 2.47, 95 % CI = 1.57-3.88). A subsequent subgroup analysis by Helicobacter pylori-positive ratio in cases (>80 %) indicated an enhancement in the association with precancerous lesions (OR = 3.43, 95 % CI = 1.92-6.13). The TLR4 +896A/G SNP is a risk factor in gastric carcinogenesis, especially in H. pylori-infected patients with precancerous lesions.

Who benefits from adjuvant radiation therapy for gastric cancer? A meta-analysis

PURPOSE

Large randomized trials have demonstrated significant survival benefits with the use of adjuvant chemotherapy or chemoradiation therapy for gastric cancer. The importance of adjuvant radiation therapy (RT) remains unclear. We performed an up-to-date meta-analysis of randomized trials testing the use of RT for resectable gastric cancer.

METHODS AND MATERIALS

We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials for randomized trials testing adjuvant (including neoadjuvant) RT for resectable gastric cancer. Hazard ratios describing the impact of adjuvant RT on overall survival (OS) and disease-free survival (DFS) were extracted directly from the original studies or calculated from survival curves. Pooled estimates were obtained using the inverse variance method. Subgroup analyses were performed to determine whether the efficacy of RT varies with chemotherapy use, RT timing, geographic region, type of nodal dissection performed, or lymph node status.

RESULTS

Thirteen studies met all inclusion criteria and were used for this analysis. Adjuvant RT was associated with a significant improvement in both OS (HR = 0.78, 95% CI: 0.70-0.86, P<.001) and DFS (HR = 0.71, 95% CI: 0.63-0.80, P<.001). In the 5 studies that tested adjuvant chemoradiation therapy against adjuvant chemotherapy, similar effects were seen for OS (HR = 0.83, 95% CI: 0.67-1.03, P=.087) and DFS (HR = 0.77, 95% CI: 0.91-0.65, P=.002). Available data did not reveal any subgroup of patients that does not benefit from adjuvant RT.

CONCLUSION

In randomized trials for resectable gastric cancer, adjuvant RT provides an approximately 20% improvement in both DFS and OS. Available data do not reveal a subgroup of patients that does not benefit from adjuvant RT. Further study is required to optimize the implementation of adjuvant RT for gastric cancer with regard to patient selection and integration with systemic therapy.

D2 lymphadenectomy is not only safe but necessary in the era of neoadjuvant chemotherapy

Background

Patients with locally advanced resectable gastric cancers are increasingly offered neoadjuvant chemotherapy (NACT) following the MAGIC and REAL-2 trials. However, information on the toxicity of NACT, its effects on perioperative surgical outcomes and tumor response is not widely reported in literature.

Methods

Analysis of a prospective database of gastric cancer patients undergoing radical D2 gastrectomy over 2 years was performed. Chemotherapy-related toxicity, perioperative outcomes and histopathological responses to NACT were analyzed. The data is presented and compared to a cohort of patients undergoing upfront surgery in the same time period.

Results

In this study, 139 patients (42 female and 97 male patients, median age 53 years) with gastric adenocarcinoma received NACT. Chemotherapy-related toxicity was noted in 32% of patients. Of the 139 patients, 129 underwent gastrectomy with D2 lymphadenectomy, with 12% morbidity and no mortality. Major pathological response of primary tumor was noted in 22 patients (17%). Of these 22 patients, lymph node metastases were noted in 12 patients. The median blood loss and lymph node yield was not significantly different to the 62 patients who underwent upfront surgery. Patients who underwent upfront surgery were older (58 vs. 52 years, P <0.02), had a higher number of distal cancers (63% vs. 82%, P <0.015) and a longer hospital stay (11 vs. 9 days, P <0.001).

Conclusions

Perioperative outcomes of gastrectomy with D2 lymphadenectomy for locally advanced, resectable gastric cancer were not influenced by NACT. The number of lymph nodes harvested was unaltered by NACT but, more pertinently, metastases to lymph nodes were noted even in patients with a major pathological response of the primary tumor. D2 lymphadenectomy should be performed in all patients irrespective of the degree of response to NACT.

A meta-analysis of interleukin-10 -592 promoter polymorphism associated with gastric cancer risk

We aimed to explore the role of IL-10 -592 A/C SNP in the susceptibility to gastric cancer through a systematic review and meta-analysis. Each initially included article was scored for quality appraisal. 17 studies were eligible for the meta-analysis. We adopted the most probably appropriate genetic model (recessive model). Potential sources of heterogeneity were sought out via subgroup and sensitivity analyses, and publication biases were estimated. IL-10-592 AA genotype is associated with the reduced risk of developing gastric cancer among Asians and even apparently observed among Asians high quality subgroup, suggesting IL-10-592 AA genotype may seem to be more protective from overall gastric cancer in Asian populations. IL-10-592 AA genotype is also associated with the overall reduced gastric cancer susceptibility in persons with H. pylori infection compared with controls without H. pylori infection, suggesting IL-10-592 AA genotype may seem to be more protective from overall gastric cancer susceptibility in persons infected with H. pylori. IL-10-592 AA genotype is not associated with either pathologic subtypes (intestinal or diffuse) or anatomic subtypes (non-cardia or cardia) of gastric cancer susceptibility. Genotyping methods like direct sequencing should be highly advocated to be conducted in future well-designed high quality studies among different ethnicities or populations.

Interleukin-10-819 promoter polymorphism in association with gastric cancer risk

Background

Potential functional allele T/C single nucleotide polymorphism (SNP) of Interleukin 10 (IL-10) promoter -819 (rs1800871) has been implicated in gastric cancer risk. We aimed to explore the role of T/C SNP of IL-10 -819 in the susceptibility to gastric cancer through a systematic review and meta-analysis.

Methods

Each initially included article was scored for quality appraisal. Desirable data were extracted and registered into databases. 11 studies were ultimately eligible for the meta-analysis of IL-10 -819 T/C SNP. We adopted the most probably appropriate genetic model (recessive model). Potential sources of heterogeneity were sought out via subgroup and sensitivity analyses, and publication biases were estimated.

Results

IL-10 -819 TT genotype is associated with the overall reduced gastric cancer risk among Asians and even apparently observed among high quality subgroup Asians. IL-10-819 TT genotype is not statistically associated with the overall reduced gastric cancer susceptibility in persons with H. pylori infection compared with controls without H. pylori infection. IL-10 -819 TT genotype is reversely associated with diffuse-subtype risk but not in intestinal-subtype risk. IL-10 -819 TT genotype is not reversely associated with non-cardia or cardia subtype gastric cancer susceptibility.

Conclusions

IL-10 -819 TT genotype seems to be more protective from gastric cancer in Asians. Whether IL-10 -819 TT genotype may be protective from gastric cancer susceptibility in persons infected with H. pylori or in diffuse-subtype cancer needs further exploring in the future well-designed high quality studies among different ethnicity populations. Direct sequencing should be more used in the future.