Staging laparoscopy for advanced gastric cancer: is it also useful for the group which has an aggressive surgical strategy?

Usefulness of Diagnostic Staging Laparoscopy for Advanced Gastric Cancer

BACKGROUND

For advanced gastric cancer (AGC), peritoneal metastasis is the most common determinant of unresectability, but accurate preoperative diagnosis for peritoneal metastasis is challenging. Staging laparoscopy (SL) can detect unsuspected peritoneal metastasis. This study retrospectively evaluated the utility of SL and its indication in patients with AGC.

METHODS

In this study, we enrolled 114 patients with pathologically diagnosed gastric adenocarcinoma who underwent SL.

RESULTS

Of the 114 patients, 43 (37.7%) had peritoneal metastasis (P1 or CY1). Higher age, larger tumor size, type 4 GC, deeper tumor depth, elevated CA125, and ascites findings in preoperative CT were found to be significant predictors of peritoneal metastasis. In multivariate analysis, peritoneal metastasis was associated with type 4 GC (odds ratio [OR]: 6.11; 95% confidence interval [CI]: 1.87-19.8; P < .01) and ascites in CT (OR: 4.25; 95% CI: 1.48-12.1; P < .01).

CONCLUSIONS

Staging laparoscopy is an effective tool to detect peritoneal metastasis from AGC. It can increase the curative resection rate and decrease unnecessary laparotomies.

Gastric Cancer with Radiographically Occult Metastatic Disease: Biology, Challenges, and Diagnostic Approaches

Gastric adenocarcinoma is an aggressive cancer that demonstrates heterogeneous biology depending on patient ethnicity, tumor location, tumor type, and genetic profile. It remains the third leading cause of cancer deaths worldwide and was estimated to result in 782,000 deaths in 2018. Challenges exist in accurately assessing the disease burden, as available radiological staging often underestimates metastatic disease. This diagnostic handicap, along with the poor understanding of the heterogeneous biology of gastric cancer, has hindered the development of effective therapeutic solutions and thus halted improvement in patient outcomes over the last few decades. The management of occult peritoneal disease is complicated, as most patients are understaged by standard imaging studies and therefore thought to have local diseases. In this article, we systematically review recent literature on the limitations that are associated with standard radiographic staging, discuss recent molecular biology advances to better identify and diagnose occult peritoneal disease, and propose possible management strategies to approach this complicated clinical problem.

Yield of staging laparoscopy in gastric cancer is influenced by Laurén histologic subtype

BACKGROUND

Staging laparoscopy (SL) with cytologic lavage is a useful staging procedure that allows tailoring the treatment of advanced gastric cancer (GC). The current study aimed to evaluate the total yield of SL in patients with various Laurén histo-types of GC, before planned neoadjuvant chemotherapy and gastrectomy.

METHODS

After exclusion of distant metastatic disease on imaging modalities, 173 patients with primary advanced gastric adenocarcinoma who underwent SL between August 2016 and September 2018, were eligible for the analysis. Patients sex, age, Lauren histo-type, tumor location, grade, cT, and cN were assessed in bivariate analysis. Multivariable logistic regression analysis was used to identify independent factors associated with peritoneal metastases.

RESULTS

Peritoneal metastases, ascites, and positive cytology were found in 39 (22.5%), 17 (9.8%) and 38 (22%) patients, respectively. The total yield of the SL in the current study was 36.4%. Multivariable logistic regression analysis revealed that serosal involvement (cT4) and diffuse histo-type were independent predictors of peritoneal metastases (OR, 15; 95% CI, 1.9-119, P = .02 and OR, 2.4; 95% CI, 1.2-4.6, P = .01, respectively).

CONCLUSIONS

Although cT4 and diffuse tumors show the highest association with peritoneal metastases, SL is a valuable diagnostic procedure in all advanced GC patients.

Conversion Surgery for Gastric Cancer with Peritoneal Metastasis Based on the Diagnosis of Second-Look Staging Laparoscopy

BACKGROUND

Patients with positive peritoneal cytology (CY1) or peritoneal dissemination (P1) have significantly poor prognosis. We performed pre-therapeutic staging laparoscopy (SL) to diagnose peritoneal metastasis for patients with advanced gastric cancer. When peritoneal metastasis disappears by chemotherapy for patients with CY1 or P1, we have intention to perform conversion surgery (CS). This study aims to clarify the clinical significance of CS for such patients.

METHODS

We retrospectively analyzed clinical outcomes of 115 patients with advanced gastric cancer (large type 3, type 4, serosa-invasion) who underwent SL between 2005 and 2014. Disappearance of peritoneal metastasis was confirmed by second-look SL.

RESULTS

CY0P0, CY1P0, and P1 were found in 56, 26, and 33 patients, respectively. In patients with CY1P0, 12 patients (66.7%) underwent CS (R0) as peritoneal cytology turned negative. All cases received S-1-based regimens, with median five treatment courses. The survival of patients with CS was significantly longer than those without CS (median survival time (MST); 41 vs. 11 months, respectively, P < 0.001). We observed no difference in overall survival between patients who underwent CS and patients with CY0P0 at the first SL (P = 0.913). All patients with P1 received chemotherapy. As peritoneal metastasis of five patients (15.2%) disappeared by chemotherapy, those patients underwent the CS (R0). The survival of patients who underwent CS was significantly longer than those who did not (MST; 31 vs. 10 months, respectively, P = 0.034).

CONCLUSION

This study suggests that conversion surgery contributes to improvement in survival of patients with peritoneal metastasis.

The neutrophil/lymphocyte ratio as a predictor of peritoneal metastasis during staging laparoscopy for advanced gastric cancer: a retrospective cohort analysis

BACKGROUND

The use of staging laparoscopy (SL) has become widespread in patients with advanced gastric cancer (GC). This study aimed to evaluate the predictive value of the neutrophil/lymphocyte ratio (NLR) for the presence of peritoneal metastasis during staging laparoscopy in patients with advanced GC.

METHODS

This retrospective analysis was performed in 35 patients with advanced GC who underwent SL at Kanazawa Medical University Hospital between January 2009 and December 2017. Clinicopathological characteristics were examined and multivariate analyses were performed to identify preoperative laboratory parameters that were independently associated with the presence of peritoneal metastasis or cytological malignancy (P/CY positive) during SL.

RESULTS

A P/CY-positive result was confirmed during SL in 16 patients (45.7%). Patients with type 4 or diffuse type 3 tumors showed a significantly higher P/CY-positive rate than those with other tumor types (58.3% vs. 18.2%, P = 0.02). In the univariate analysis for preoperative laboratory parameters, NLR (P < 0.0001) and total protein (P = 0.03) and albumin (P = 0.04) levels were significantly correlated with a P/CY-positive result. On multivariate analysis, NLR was significantly correlated with a P/CY-positive result (P = 0.0002). In patients with type 4 or diffuse type 3 tumors, a high NLR (> 3.5) was associated with a significantly higher P/CY-positive rate than a low NLR (≤ 3.5) (83.3% vs. 33.3%, P = 0.01). Moreover, in patients without type 4 or diffuse type 3 tumors, the P/CY-positive rates were 100% and 0% in patients with NLR > 3.5 and NLR ≤ 3.5, respectively.

CONCLUSIONS

The preoperative NLR was a significant independent predictor of the presence of peritoneal metastasis during SL. Regardless of tumor type, patients with a high NLR could be reasonable candidates for SL. On the other hand, non-diffuse type tumor accompanied by a low NLR may not need to undergo SL.

Gastric Cancer: Recent Molecular Classification Advances, Racial Disparity, and Management Implications

Gastric adenocarcinoma remains an aggressive and poorly understood malignancy with a heterogeneous presentation and tumor biology. The current histologic and anatomic classification has been ineffective in guiding therapy, with only marginal improvement in outcome over time. Furthermore, the variation in presentation and disease among racial and ethnic groups amplifies the complexity of this cancer. An understanding of the clinical and molecular variability is important for effective treatment. Recent advances in molecular biology have better defined gastric cancer subtypes. We systematically review recent literature on the molecular classification of gastric adenocarcinoma and the associated management implications, with an emphasis on Hispanic and Native American populations.

Effects of CO2 pneumoperitoneum on proliferation, apoptosis, and migration of gastrointestinal stromal tumor cells

BACKGROUND

The purpose of the study was to investigate the proliferation and migration capability of human gastrointestinal stromal tumor line GIST-T1 after exposure to different pressures and times of CO₂ pneumoperitoneum.

METHODS

We established simulated CO₂ pneumoperitoneum environment in vitro and divided the human GIST cell GIST-T1 into open control group, 8 mmHg CO₂ pneumoperitoneum treatment group and 15 mmHg CO₂ pneumoperitoneum treatment group. Each group was divided into two subgroups respectively cultured for 1 h and 3 h. pH value of cell culture, cell growth curve, and cell cycle distribution of each group was measured. By application of scratch healing tests and Transwell chamber experiments, mobility ratio and number of cells through 8 µm membranes were measured to assess the migration ability of cells in each group after intervention.

RESULTS

Cell culture pH value of each subgroup in CO₂ group decreased significantly after exposed in CO₂ pneumoperitoneum (P < 0.01). The proliferation of GIST-T1 cells in 15 mmHg CO₂ group was significantly inhibited early (1-2 days) (P < 0.05) and the proliferation of GIST-T1 cells in 8 mmHg CO₂ 1 h subgroup and 15 mmHg CO₂ 1 h subgroup was increased significantly late (4-6 days) (P < 0.05) after the interventions of CO₂ pneumoperitoneum. The percentage of cells in G0-G1 phase increased, the percentage of S phase cells decreased (P < 0.01) in 1-h subgroup and 3-h subgroup of 15 mmHg CO₂ group 24 h after exposure to CO₂. The percentage of cells in S phase increased in 1-h subgroup of 8 mmHg CO₂ group and decreased in 3-h subgroup of 15 mmHg CO₂ group 72 h after exposure to CO₂. In the Transwell chamber experiment, the cell number through 8-µm membrane increased significantly (P < 0.01) in 3-h subgroup of CO₂ group compared to that in 3-h subgroup of control group.

CONCLUSIONS

The routine pressure and duration of CO₂ pneumoperitoneum used in clinic did not promote the proliferation of gastrointestinal stromal tumors, but had a potential risk of increasing postoperative recurrence and distant metastasis.

The Yield of Staging Laparoscopy in Gastric Cancer is Affected by Racial and Ethnic Differences in Disease Presentation

BACKGROUND

Gastric cancer is a heterogeneous disease with variable presentation between racial and ethnic groups. Staging laparoscopy (SL) detects occult metastases not visible on cross-sectional imaging and therefore improves staging. It remains unclear how differences in race and ethnicity affect disease presentation and the yield of SL.

METHODS

We performed a retrospective review of a prospectively maintained database to identify patients with gastric cancer treated with curative intent at our institutions from 2008 to 2015.

RESULTS

Hispanic patients presented at an earlier mean age (55.5 ± 11.9 years) compared with Asian (59.8 ± 13.9 years), African American (61.0 ± 10.0 years), and white patients (61.7 ± 12.5 years; p = 0.046) and with more locally advanced disease (clinical stage T3/T4 or node positive; Hispanic 87%; African American 79%; white 68%, Asian 55%; p = 0.03). SL identified 42 patients (34%) with occult metastatic disease. Hispanics were more likely to have a positive SL (44%) than white patients (21%; p = 0.04). On univariate analysis, Hispanic ethnicity, clinical T3/T4, positive nodal disease, signet ring cells, and poor differentiation were predictors of a positive SL. On multivariable analysis, clinical T3/T4, signet ring cells, and poor differentiation independently predicted radiographically occult disease.

CONCLUSIONS

Hispanic patients presented with more locally advanced disease and were more likely to have occult disease found on SL compared with white patients. Laparoscopy should be used routinely as part of the pretreatment staging evaluation for patients with locally advanced disease as it alters the management in a significant proportion of patients.

Impact of clinical tumor-node-metastasis staging on survival in gastric carcinoma patients receiving surgery

BACKGROUND

Preoperative clinical staging of gastric cancer is used to determine therapeutic strategies. However, the impact of the clinical stage on survival has not been completely investigated, although the relationship between pathologic staging and survival outcome has been reported. The aim of the present study was to clarify the predictability of patient survival based on clinical staging and to evaluate the usefulness of staging as an indicator for selecting the treatment modality.

METHODS

A total of 3033 patients who underwent surgery for gastric cancer were included. A survival analysis was conducted based on the seventh edition of the tumor-node-metastasis (TNM) clinical staging system of the American Joint Committee on Cancer. The predictive ability of the TNM clinical stage for survival was evaluated by Harrell's C-index, a measure of the separation of survival distributions.

RESULTS

The cumulative 5-year survival rates according to the clinical stage were 94.3 % (IA), 84.7 % (IB), 71.7 % (IIA), 56.1 % (IIB), 55.7 % (IIIA), 42.3 % (IIIB), 22.8 % (IIIC), and 9.1 % (IV). Although no significant difference was observed between clinical stages IIB and IIIA (p = 0.865), significant differences existed between all other clinical stages (p < 0.001). Harrell's C-index applied to these results was 0.825 (95 % confidence interval 0.819-0.831).

CONCLUSIONS

The seventh edition of the TNM clinical staging system has a strong prognostic ability with a satisfactory C-index and should be considered valuable for selecting therapeutic strategies for the treatment of gastric cancer.

Effectiveness of laparoscopic stomach-partitioning gastrojejunostomy for patients with gastric outlet obstruction caused by advanced gastric cancer

BACKGROUND

Distal advanced gastric cancer (AGC) occasionally causes gastric outlet obstruction (GOO). We developed a laparoscopic stomach-partitioning gastrojejunostomy (LSPGJ) to restore the ability of food intake.

METHODS

This was a retrospective study performed at a single institution. Of consecutive 78 patients with GOO caused by AGC between 2006 and 2012, 43 patients who underwent LSPGJ were enrolled. The procedure was performed in an antiperistaltic Billroth II fashion, and the afferent loop was elevated and fixed along the staple line of the proximal partitioned stomach. Then, patients for whom R0 resection was planned received chemotherapy prior to laparoscopic gastrectomy. The primary end point was food intake at the time of discharge, which was evaluated using the GOO scoring system (GOOSS). Short- and long-term outcomes were assessed as secondary end points. Overall survival was estimated and compared between the groups who received neoadjuvant chemotherapy followed by surgery (NAC group), definitive chemotherapy followed by curative resection (Conversion group), and best supportive care (BSC group).

RESULTS

The median operative time was 92 min, blood loss did not exceed 30 g in any patient, and postoperative complications (Clavien-Dindo grade ≥2) were only seen in four patients (9.3 %). The median time to food intake was 3 days, and GOOSS scores were significantly improved in 41 patients (95.3 %). Chemotherapy was administered to 38 patients (88.4 %), of whom 11 later underwent radical resection, and 4 of 11 patients underwent conversion surgery following definitive chemotherapy. Median survival times were significantly superior in the NAC (n = 7; 46.8 months) and Conversion (n = 4; 35.9 months) groups than in the BSC group (n = 26; 12.2 months); however, the difference was not significant between the Conversion and NAC groups.

CONCLUSIONS

LSPGJ is a feasible and safe minimally invasive induction surgery for patients with GOO from surgical and oncological perspectives.

Detection value of free cancer cells in peritoneal washing in gastric cancer: a systematic review and meta-analysis

Intraperitoneal free cancer cells in gastric adenocarcinoma are associated with a poor outcome. However, the true prognostic value of intraperitoneal free cancer cells is still unclear, leading to a lack of consensus in the management of gastric cancer. The aim of the present study is to perform a systematic review and meta-analysis to analyze intraperitoneal free cancer cells-positive patients with regard to tumor oncologic stage, recurrence, grade of cellular differentiation, and survival rates and to analyze the clinical significance of intraperitoneal free cancer cells with regard to prognosis. Databases were searched up to January 2016 for prognostic factors associated with intraperitoneal free cancer cells, including oncologic stage, depth of neoplasm invasion, lymph nodal spread, differentiation grade of the tumor, and recurrence and survival rates. A total of 100 studies were identified. Meta-analysis revealed a clear association between intraperitoneal free cancer cells and a poor prognosis. intraperitoneal free cancer cells -positive patients had higher rates of nodal spread (risk difference: 0.29; p<0.01), serosal invasion (risk difference: 0.43; p<0.01), recurrence (after 60 months of follow-up, risk difference: 0.44; p<0.01), and mortality (after 60 months of follow-up, risk difference: 0.34; p<0.01). Intraperitoneal free cancer cells are associated with a poor outcome in gastric cancer. This surrogate biomarker should be used to guide therapy both prior to and after surgery.

Greater Omental Milky Spot Examination for Diagnosis of Peritoneal Metastasis in Gastric Cancer Patients

OBJECTIVE

To evaluate the diagnostic value of cytological greater omental milky spot examination for the diagnosis of peritoneal metastasis in gastric cancer patients.

METHODS

A total of 136 patients diagnosed with gastric cancer and without distant metastasis were enrolled in our study. All patients underwent laparoscopy and CH40 suspension liquid dye of peritoneal lymph nodes preoperatively as well as ascites or peritoneal lavage fluid collections and excisions of marked greater omental milky spot tissues perioperatively.

RESULTS

According to the laparoscopic results, the patients were divided into T1-T2 stage (n = 56) without and into T3-T4 stage (n = 80) with tumor invasion into the serosal layer. Among the T1-T2-stage patients, tumor cells could be detected in peritoneal lavage fluids in 2 cases, whereas with greater omental milky spot examination, peritoneal metastasis was detected in 8 cases. Among the 80 cases in the T3-T4 stage, tumor cells could be detected in 28 cases via peritoneal lavage cytology and in 43 cases by greater omental milky spot examinations, and 4 cases had cancer cell infiltration also in nonmilky spot omental areas. The statistical analysis showed that the staging accuracy rate of exfoliative cytology examination was superior to that of the laparoscopic exploration (P < .05), but its sensitivity was significantly lower than that obtained with cytological greater omental milky spot examinations (P < .05).

CONCLUSIONS

The laparoscopic exploration could make a preliminary diagnosis of peritoneal metastasis via serosal layer invasion detection. For further analyses, cytological examinations of greater omental milky spots were more sensitive than exfoliative cytology.

Recent insights in the therapeutic management of patients with gastric cancer

Gastric cancer remains frequent and one of the most lethal malignancies worldwide. In this article, we aimed to comprehensively review recent insights in the therapeutic management of gastric cancer, with focus on the surgical and perioperative management of resectable forms, and the latest advances regarding advanced diseases. Surgical improvements comprise the use of laparoscopic surgery including staging laparoscopy, a better definition of nodal dissection, and the development of hyperthermic intraperitoneal chemotherapy. The best individualized perioperative management should be assessed before curative-intent surgery for all patients and can consists in perioperative chemotherapy, adjuvant chemo-radiation therapy or adjuvant chemotherapy alone. The optimal timing and sequence of chemotherapy and radiation therapy with respect to surgery should be further explored. Patients with advanced gastric cancer have a poor prognosis. Nevertheless, they can benefit from doublet or triplet chemotherapy combination, including trastuzumab in HER2-positive patients. Upon progression, second-line therapy can be considered in patients with good performance status. Although anti-HER2 (trastuzumab) and anti-VEGFR (ramucirumab) may yield survival benefit, anti-EGFR and anti-HGFR therapies have failed to improve outcomes. Nevertheless, combination regimens containing cytotoxic drugs and targeted therapies should be further evaluated; keeping in mind that gastric cancer biology is different between Asia and the Western countries.

Real-time optical diagnosis of gastric cancer with serosal invasion using multiphoton imaging

A real-time optical biopsy, which could determine tissue histopathology, would be of extraordinary benefit to staging laparoscopy for gastric cancer with serosal invasion (T4) that requires downstage treatment. We investigated the feasibility of using multiphoton imaging to perform a real-time optical diagnosis of gastric cancer with or without serosal invasion. First, a pilot study was performed to establish the optical diagnostic features of gastric cancer with or without serosal invasion using multiphoton imaging compared with hematoxylin-eosin staining and Masson’s trichrome staining. Second, a blinded study was performed to compare the diagnostic sensitivity, specificity, and accuracy of multiphoton imaging and endoscopic ultrasonography (EUS) for T4 gastric cancer. In the pilot study, multiphoton imaging revealed collagen loss and degradation and cellular and nuclear pleomorphism in gastric cancer with serosal invasion. The collagen content in gastric cancer with or without serosal invasion was 0.36 ± 0.18 and 0.79 ± 0.16 (p < 0.001), respectively. In the blinded study, the sensitivity, specificity, and accuracy of EUS and multiphoton imaging for T4 gastric cancer were 70% and 90% (p = 0.029), 66.67% and 96.67% (p = 0.003), and 68.33% and 93.33% (p = 0.001), respectively. It is feasible to use multiphoton imaging to make a real-time optical diagnosis of gastric cancer with or without serosal invasion.

Staging laparoscopy improves treatment decision-making for advanced gastric cancer

AIM

To evaluate the clinical value of staging laparoscopy in treatment decision-making for advanced gastric cancer (GC).

METHODS

Clinical data of 582 patients with advanced GC were retrospectively analyzed. All patients underwent staging laparoscopy. The strength of agreement between computed tomography (CT) stage, endoscopic ultrasound (EUS) stage, laparoscopic stage, and final stage were determined by weighted Kappa statistic (Kw). The number of patients with treatment decision-changes was counted. A χ(2) test was used to analyze the correlation between peritoneal metastasis or positive cytology and clinical characteristics.

RESULTS

Among the 582 patients, the distributions of pathological T classifications were T2/3 (153, 26.3%), T4a (262, 45.0%), and T4b (167, 28.7%). Treatment plans for 211 (36.3%) patients were changed after staging laparoscopy was performed. Two (10.5%) of 19 patients in M1 regained the opportunity for potential radical resection by staging laparoscopy. Unnecessary laparotomy was avoided in 71 (12.2%) patients. The strength of agreement between preoperative T stage and final T stage was in almost perfect agreement (Kw = 0.838; 95% confidence interval (CI): 0.803-0.872; P < 0.05) for staging laparoscopy; compared with CT and EUS, which was in fair agreement. The strength of agreement between preoperative M stage and final M stage was in almost perfect agreement (Kw = 0.990; 95% CI: 0.977-1.000; P < 0.05) for staging laparoscopy; compared with CT, which was in slight agreement. Multivariate analysis revealed that tumor size (≥ 40 mm), depth of tumor invasion (T4b), and Borrmann type (III or IV) were significantly correlated with either peritoneal metastasis or positive cytology. The best performance in diagnosing P-positive was obtained when two or three risk factors existed.

CONCLUSION

Staging laparoscopy can improve treatment decision-making for advanced GC and decrease unnecessary exploratory laparotomy.

Clinical utility of perioperative staging laparoscopy for advanced gastric cancer

BACKGROUND

Perioperative staging laparoscopy is a useful tool for the detection of occult peritoneal metastases in gastrointestinal cancers. This retrospective study aimed to determine the clinical value of staging laparoscopy for advanced or recurrent gastric cancer.

METHODS

A total of 178 patients with advanced or recurred gastric cancer who underwent perioperative staging laparoscopy were enrolled. In the absence of peritoneal deposits (P1) and positive peritoneal cytology (CY1), gastrectomy with lymph node dissection was indicated with curative intent. If P1 or CY1 was detected intraoperatively, patients received intensive chemotherapy and laparoscopic surgical intervention.

RESULTS

Curative gastrectomy was performed in 104 patients after confirmation of P0 and CY0 status. P1 or CY1 was detected for the first time in 23 (15%) patients. A total of 13 patients were converted from gastrectomy to intensive chemotherapy after detection of P1 or CY1. Additional laparoscopic interventions included insertion of intraperitoneal reservoir port in 54 patients, insertion of a metallic stent in five, ileostomy for colon stricture in six, jejunostomy in 19, and gastrojejunostomy in 16. Of eight patients treated with intensive chemotherapy who underwent R0 gastrectomy after second-look laparoscopy, five are currently free from recurrence of gastric cancer for 25.5 months.

CONCLUSIONS

Occult peritoneal dissemination was detected in about 14% in patients with tumors deeper than T2. Moreover, additional laparoscopic interventions can be utilized for P1 or CY1 patients. The excellent surgical outcomes of R0 gastrectomy after chemotherapy and second-look laparoscopy indicate that confirmation of P0 and CY0 status by staging laparoscopy is of value to determine treatment strategy in patients with advanced gastric cancer.

Preoperative plasma fibrinogen level is a useful predictor of adjacent organ involvement in patients with advanced gastric cancer

Purpose

The aim of the present study was to assess the association between the pre-operative plasma fibrinogen level and the adjacent organ involvement in advanced gastric cancer.

Materials and Methods

A total of 923 pre-operative plasma samples were obtained from 923 patients diagnosed clinically as having advanced gastric cancer, and fibrinogen levels were measured by immunoassay. Associations between fibrinogen levels and clinicopathologic findings (depth of tumor, adjacent organ involvement, and lymph node metastasis), along with survival were examined by univariate and multivariate analyses.

Results

Tumor size, tumor depth, and the presence of lymph node metastasis were found to be positively correlated with the preoperative plasma fibrinogen levels (P<0.001). Fifty (5.4%) patients had adjacent organ involvement. Lymphatic invasion (P<0.001), tumor size (P<0.001), clinical T (depth of invasion) stage (P<0.001), and clinical nodal stage (P=0.018) were found to be associated with adjacent organ involvement. Univariate and multivariate regression analyses showed that a preoperatively elevated plasma fibrinogen level was associated with adjacent organ involvement (P<0.001, 0.028), and Kaplan-Meier analysis showed that it was associated with poorer survival (P<0.001).

Conclusions

Plasma fibrinogen was found to be a clinically useful marker of adjacent organ involvement and overall survival. When a high fibrinogen level is encountered, preoperatively, adjacent organ involvement should be suspected in clinically advanced gastric cancer.

Morbidity and mortality after non-curative gastrectomy for gastric cancer in elderly patients

BACKGROUND AND OBJECTIVES

This study examined the surgical outcome of non-curative resection in elderly patients with gastric cancer.

METHODS

The study reviewed 278 patients who underwent non-curative resection for advanced gastric cancer. The clinicopathological features of elderly patients (≥ 75 years, n = 257) and younger patients (<75 years, n = 21) were compared.

RESULTS

Although no difference was observed in terms of preoperative performance, there were distinct differences in terms of albumin level, presence of symptoms, and the rate of comorbidities between the two groups. The postoperative morbidity and mortality rate did not differ between the two groups. Age, preoperative performance status, preoperative transfusion, and presence of comorbidity were not independent predictors of postoperative complications. However, the extent of gastric resection and combined resection were closely related to postoperative complications in patients with non-curative gastrectomy.

CONCLUSIONS

In a setting of non-curative resection for gastric cancer, age was not a limiting factor. Rather, the risk of postoperative morbidity should be considered carefully in total gastrectomy and combined resection.

Indications for staging laparoscopy in clinical T4M0 gastric cancer

BACKGROUND

This study was undertaken to determine the efficacy of the clinical indications for performing staging laparoscopy for locally advanced gastric cancer to detect peritoneal metastasis or positive cytology findings.

METHODS

The study included 231 patients with T4 gastric cancer without hematogenous or clinically evident peritoneal metastasis. The clinicopathologic features, including T and N factors, were diagnosed by clinical staging. The relation between the clinicopathologic features and the presence of peritoneal metastasis or lavage cytology at surgery was analyzed.

RESULTS

A total of 31 patients underwent staging laparoscopy; 200 others underwent open surgery as a primary treatment. Both peritoneal metastasis and lavage cytology were negative in 145 (62.8%) patients, whereas peritoneal metastasis or lavage cytology was positive in 86 patients (37.2%). When calculating diagnostic accuracy in the 23 patients who underwent open laparotomy after staging laparoscopy, the accuracy rate was 95.7%. A multivariate analysis showed that a tumor location involving three portions; macroscopic type 3, 4, or 5; and positive lymph node metastasis to all three is significantly correlated with either peritoneal metastasis or positive cytology. When patients had two or three factors among these three independent risk factors, peritoneal metastasis or positive cytology could be detected with 91.9% sensitivity and 46.7% positive predictive value.

CONCLUSIONS

The selection of T4 tumors based on clinically evaluable risk factors is therefore considered useful for detecting peritoneal metastasis efficiently and hence avoiding unnecessary staging laparoscopy.

Gastric cancer surgery: an American perspective on the current options and standards

Gastric cancer is prevalent globally, particularly in Asian countries such as Japan and Korea. While the prevalence of gastric cancer is not nearly as high in the United States (U.S.) as in Asia, the treatment armamentarium differs widely between regions. The role of surgery for gastric cancer in the U.S. has changed drastically over the last decade. While the natural history of gastric cancer seen in the U.S. markedly differs from that seen in Asia, the U.S. experience with endoscopic and minimally invasive techniques is beginning to parallel those seen in Japan and Korea. Minimally invasive surgery has truly come into the forefront of our surgical armamentarium, and its role, along with robotic and endoscopic approaches, remains to be defined as standard of care. At present, minimally invasive approaches appear to offer oncologically equivalent outcomes compared with standard open gastrectomy when performed by experienced surgeons. Extended lymphadenectomy does not appear to offer benefit with improved survival in our patient population, although sufficient lymph node sampling is imperative for adequate staging. Despite aggressive approaches to surgical resection for cure, the U.S. population tends to present with more advanced disease and have a worse prognosis than our Asian counterparts. Palliation with resection and possibly stent placement should be offered for improved quality of life in late-stage disease.

Use of laparoscopy as an alternative to computed tomography (CT) and positron emission tomography (PET) scans for the detection of recurrence in patients with gastric cancer: a pilot study

BACKGROUND

This study aimed to evaluate laparoscopy as a diagnostic method for detecting recurrence in patients with advanced gastric cancer.

METHODS

Diagnostic laparoscopy was performed for 12 patients with insufficient evidence of intraabdominal gastric cancer recurrence by computed tomography or positron emission tomography. By comparing laparoscopic observations with conventional radiologic results, the diagnostic accuracy of laparoscopy was assessed.

RESULTS

In 11 (92%) of 12 cases of recurrence not diagnosed by imaging studies, laparoscopic examination confirmed the case as a recurrence. Using diagnostic laparoscopy, retroperitoneal lymph node recurrence was confirmed in two patients, peritoneal seeding nodules in five patients, and recurrent masses invading the mesocolon in two patients. Two patients had no definitive recurrence grossly but were confirmed as recurrence cases by washing cytology during the laparoscopic procedure. One patient had a duodenal stump recurrence. No patients experienced operation-related morbidity.

CONCLUSION

Laparoscopy is a safe and feasible method for detecting recurrence with acceptable accuracy. This approach provides more accurate information than conventional imaging methods.

Recent advances in preoperative staging of gastric cancer

A more differentiated therapy regimen for gastric carcinoma requires more precise preoperative staging. In patients with early gastric cancer (EGC), especially in cases with carcinoma confined to mucosa, endoscopic resection (ER) is usually performed to avoid unnecessary surgical procedures. To achieve R0 resection for locally advanced gastric cancer (AGC), neoadjuvant treatments have been investigated. Clinical staging of gastric cancer has been greatly improved by advances in imaging techniques, such as endoscopic ultrasonography (EUS), transabdominal ultrasonography (TAUS), multi-slice spiral CT (MSCT), magnetic resonance imaging (MRI), positron emission tomography (PET), combined PET-CT scans, and laparoscopic staging. This paper aims to summarize the recent advances in preoperative staging of gastric cancer.

Predicting factors of unexpected peritoneal seeding in locally advanced gastric cancer: indications for staging laparoscopy

BACKGROUND AND OBJECTIVES

The aim of this study is to investigate predictive factors for unexpected peritoneal seeding from clinically resectable advanced gastric cancers to suggest the indications for staging laparoscopy (SL).

METHODS

A total of consecutive 589 gastric cancer patients who were clinically diagnosed with advanced gastric cancer with no metastatic disease underwent operations at Seoul St. Mary's Hospital.

RESULTS

A total of 72 patients (including 35 patients with seeding to distant peritoneum) were surgically diagnosed with peritoneal seeding. Borrmann type 3 (OR: 4.475) or type 4 (OR: 8.243) cancer, tumor invasion of T3 (OR: 2.794) or T4 (OR: 6.841) and tumor size (4  cm  ≤  tumor size  <  8  cm; OR: 3.723 and 8  cm  ≤  tumor size; OR: 6.971) were predictive factors for overall peritoneal seeding. Borrmann type 3 (OR: 3.524) or 4 (OR: 4.695) cancer, tumor invasion of T3 (OR: 4.378) or T4 (OR: 15.817), and tumors involving the anterior wall (OR: 2.762) also turned out to be predictive factors for distant peritoneal seeding.

CONCLUSIONS

If SL were performed by these predictive factors, this should have been performed in 42.4% of advanced gastric cancers and the detection rates for overall peritoneal seeding would have been 24.0%.

Peritoneal carcinomatosis from gastric cancer: a multi-institutional study of 159 patients treated by cytoreductive surgery combined with perioperative intraperitoneal chemotherapy

BACKGROUND

Peritoneal carcinomatosis (PC) from gastric cancer has long been regarded a terminal disease with a short median survival. New locoregional therapeutic approaches combining cytoreductive surgery with perioperative intraperitoneal chemotherapy (PIC) have evolved and suggest improved survival.

MATERIALS AND METHODS

A retrospective multicentric study was performed in French-speaking centers to evaluate the toxicity and the principal prognostic factors in order to identify the best indications. All patients had cytoreductive surgery and PIC: hyperthermic intraperitoneal chemotherapy (HIPEC) and/or early postoperative intraperitoneal chemotherapy (EPIC).

RESULTS

The study included 159 patients from 15 institutions between February 1989 and August 2007. The median follow-up was 20.4 months. HIPEC was the PIC used for 150 procedures. Postoperative mortality and grade 3-4 morbidity rates were 6.5 and 27.8%, respectively. By multivariate analysis, the institution had a significant influence on toxicity. The overall median survival was 9.2 months and 1-, 3-, and 5-year survival rates were 43, 18, and 13%, respectively. The only independent prognostic indicator by multivariate analysis was the completeness of cytoreductive surgery. For patients treated by complete cytoreductive surgery, the median survival was 15 months with a 1-, 3-, and 5-year survival rate of 61, 30, and 23%, respectively.

CONCLUSIONS

The therapeutic approach combining cytoreductive surgery with PIC for patients with gastric carcinomatosis may achieve long-term survival in a selected group of patients (limited and resectable PC). The high mortality rate underlines this necessarily strict selection that should be reserved to experienced institutions involved in the management of PC and gastric surgery.

The utility of pre-operative peritoneal lavage examination in serosa-invading gastric cancer patients

BACKGROUND

Peritoneal dissemination is frequently found during laparotomy in patients with serosa-invading gastric cancer. Detection of exfoliated cancer cells in abdominal lavage cytology is indicative of stage IV because of its strong association with peritoneal dissemination. Herein we have described peritoneal lavage cytology using a bedside procedure under local anesthesia.

METHODS

A prospective study of 113 patients with serosa-invading gastric cancer but without peritoneal metastases was performed. A drainage tube was inserted into the abdominal cavity for peritoneal lavage. Patients with negative cytology (CY0) were scheduled for curative gastrectomy.

RESULTS

The bedside procedure was performed safely without any complications. Lavage cytology identified CY1 in 35 (31.0%) patients and CY0 in 78 (69.0%) patients. Patients with CY0 underwent laparotomy and peritoneal lavage cytology, and 9 were found to have peritoneal disease (3 with operative CY1, 4 with peritoneal dissemination, and 2 with both operative CY1 and peritoneal dissemination). Two other patients had small, distant metastases. Finally, curative gastrectomy was achieved in 67 (59.3%) patients, but not in 46 (40.7%) patients. Thus, our bedside, pre-operative peritoneal lavage detected 76.1% (35/46) of noncurative disease before operative with a false-negative rate for detecting peritoneal disease of 20.5% (9/44). Patients with pre-operative CY1 had a poorer prognosis than pre-operative CY0 (2-year cause-specific survival 26.6% vs 82.6%).

CONCLUSION

Pre-operative bedside peritoneal lavage under local anesthesia followed by cytology is a simple and safe method for the pre-operative diagnosis of peritoneal dissemination and may help to reduce unexpected, noncurative surgery.

Octreotide acetate successfully treated a bowel obstruction caused by peritoneally disseminated gastric cancer, thereby enabling the subsequent use of oral S-1 chemotherapy

A 68-year-old woman presented with severe bowel obstruction and was subsequently diagnosed with stage IV gastric cancer with peritoneal dissemination. She was immediately stabilized in the hospital with the placement of a nasointestinal tube. Abdominal computed tomography showed multiple intraperitoneal nodules consistent with peritoneal dissemination of the gastric cancer. The patient's inability to tolerate oral intake was a contraindication to using S-1 chemotherapy, currently one of the most effective medications used for gastric cancer in Japan. Therefore, she was initially treated with octreotide acetate (OA). Her bowel obstruction was sufficiently attenuated on the seventh day after the initiation of treatment with OA to permit the initiation of oral S-1, along with low-dose cisplatin (CDDP) and radiation. S-1 was orally administered at a dose of 100 mg/day per body (80 mg/m(2) per day) on days 1-28, and CDDP was infused at a dose of 7.8 mg/day per body (6 mg/m(2) per day) on days 1-5, 8-12, and 15-19. Radiation therapy (2 Gy/day for 5 days/week) was performed with the chemotherapy. Despite no change being shown on her imaging findings with the chemotherapy, the patient's bowel obstruction resolved and she was able to tolerate both liquids and solid food orally. She was discharged 2 months after admission. Seven months after beginning the chemotherapy, she was still doing well on outpatient chemotherapy with S-1 and CDDP, and had no decline in her quality of life or progression of her disease.

Effects of simulated carbon dioxide and helium peumoperitoneum on proliferation and apoptosis of gastric cancer cells

AIM

To investigate the effects of carbon dioxide (CO(2)) and helium insufflation administered at different pressures on the growth and apoptosis of cultured human gastric cancer cells.

METHODS

The gastric cancer cells MKN-45 were exposed to a CO(2) and helium environment maintained at different pressures (0, 5, 10 and 15 mmHg). The cells were exposed to simulated pneumoperitoneum environment for 4 h, and pH of the culture media was measured after it was moved to normal conditions for 0, 2, 4, 6 and 8 h. Proliferation viability of MKN-45 was examined by 3-[4,5Dimethylthiazol-2-yl],5-diphenyltetrazolium bromide or triazolyl blue (MTT) assay after it was moved to normal conditions. Apoptotic ratio was measured by Annexin V-FITC/PI double labelled staining.

RESULTS

The pH of media was acid and recovered to normal after 4 h in the CO(2) group while it was basic in the helium group. There was no difference between CO(2) groups (under 10 mmHg ) and control group (P > 0.05) in the proliferative viability of the cells. The cultured cells exposed to 15 mmHg CO(2) environment grew more slowly than control group from 4 to 7 d (P < 0.01 ) while there was no difference from 1 to 3 d (P > 0.05). The proliferative viability in helium group was not obviously different from the control group (P > 0.05). The apoptotic ratio of the cultured cells was markedly higher than that of the control group (P < 0.01) at 10 and 15 mmHg CO(2) insufflation pressure. In helium group, the apoptotic ratio was not obviously different from the control group (P > 0.05).

CONCLUSION

There is no obvious effect in the proliferation and apoptosis of MKN-45 cells under 10 mmHg CO(2) insufflation pressure and helium in any pressure. Fifteen mmHg CO(2) insufflation pressure can inhibit the proliferation of the cells and improve apoptosis.

Risk factors and multidetector-row computed tomography evaluation of lymph node metastasis in early gastric carcinoma

AIM: To identify the risk factors predicting lymph node metastasis in early gastric carcinoma (EGC) and to investigate the value of multidetector-row computed tomography (MDCT) in the preoperative assessment of lymph node metastasis.

METHODS: Relationship between the clinicopathological parameters and lymph node metastasis in 109 EGC patients (male 64, female 45, mean age 56) who underwent preoperative MDCT examination and curative gastrectomy was retrospectively analyzed. In addition, the results of lymph node status evaluated by MDCT were compared with pathologic findings.

RESULTS: The incidence rate of lymph node metastasis was 15.60% in EGC patients. The incidence of lymph node metastasis in submucosal carcinoma was significantly higher than that in mucosal carcinoma (25.00% vs 9.23%, P = 0.026). However, the lymph node metastasis in EGC was not closely related to the gender, age of patients, tumor size, macroscopic type, tumor location, and histological type. Receiver operating characteristic (ROC) analysis further showed that the accuracy of tumor size for determination of lymph node metastasis in EGC was relatively low (area under ROC curve was 0.63). The overall accuracy of MDCT in preoperative N staging of EGC was 82.6% (N0 85.9%, N1 64.3%, N2 66.7%, respectively). The diagnostic sensitivity, specificity and accuracy of MDCT for determining lymph node metastases of EGC were 70.6%, 85.9%, and 83.5%, respectively. The diagnostic sensitivity of MDCT for determining lymph node metastasis was 50.0% in patients with solitary lymph node metastasis, while 88.89% in those with more than one lymph node metastasis. In 5 EGC patients, the lymph node metastasis was not detected by MDCT. However, the tumor size of all these 5 patients was larger than or equal to 2 cm in diameter, and both of the two mucosal carcinomas belonged to depressed EGC.

CONCLUSION: Although the clinical value of MDCT in the preoperative assessment of lymph node metastasis in patients with EGC is relatively high, we still must pay great attention to the value of lymph node metastasis-associated clinicopathological parameters in predicting lymph node status when the minimally invasive therapy is to be performed for patients with EGC.