Gastric cancer: surgery in 2011

[Evidence for the extent and oncological benefit of lymphadenectomy in gastric cancer]

The oncological standard for curative treatment of non-metastasized gastric cancer is surgical resection with systematic D2 lymphadenectomy. Early stage carcinomas (pT1a) with circumscribed prerequisites are an exception as they can be endoscopically resected; however, by infiltration of invasive gastric cancer into submucosal layers (pT1b) the risk for lymph node metastases is up to 25-28%. Due to the lack of screening programs in the western world, most gastric cancers are diagnosed in an advanced stage and the treatment is multimodal with perioperative multiple chemotherapy and increasingly more also with immunotherapy. Nevertheless, despite multidisciplinary treatment strategies, the benefits of surgical resection and an adequate systematic lymphadenectomy are still independent prognostic factors for long-term survival; however, the classification and extent of the lymphadenectomy are regularly updated, especially as a result of the spread of minimally invasive operations, and in addition are internationally evaluated differently. In the context of perioperative morbidity and oncological outcome this includes the approach with respect to individual lymph node stations, especially lymph node stations 10 and 12a and in addition the classification D1-D3. Furthermore, continuous modifications, particularly from Asia, such as sentinel lymph node resection underline the pursuit of improvements. The multitude of alterations in the context of multidisciplinary treatment concepts and the international heterogeneity make the evaluation of the value of individual surgical aspects noticeably more difficult.

Development and validation of a prognostic nomogram for esophageal cancer patients based on SEER Asian population

This study aims to develop and validate a nomogram for predicting overall survival (OS) in Asian patients with Esophageal Cancer (EC). Data from Asian EC patients were collected from the Surveillance, Epidemiology, and End Results (SEER) database. The patients were randomly divided into training and validation cohorts in a 7:3 ratio. The Least Absolute Shrinkage and Selection Operator (LASSO) regression was used for initial variable selection, followed by multivariate Cox regression analysis to identify independent prognostic factors. A nomogram was subsequently constructed based on these factors. The predictive performance of the nomogram was evaluated using receiver operating characteristic (ROC) curves and calibration curves, while the clinical utility of the nomogram was assessed through decision curve analysis (DCA). The LASSO regression and multivariate Cox regression analysis identified age, sex, marital status, tumor size, M stage, surgery, and chemotherapy as independent prognostic factors. The ROC curve results demonstrated that the area under the curve (AUC) values for predicting 1-year, 3-year, and 5-year OS in the training cohort were 0.770, 0.756, and 0.783, respectively. In the validation cohort, the AUC values were 0.814, 0.763, and 0.771, respectively. Calibration curves indicated a high concordance between predicted and actual OS. The DCA demonstrated that the nomogram has significant clinical applicability. This nomogram provides reliable predictions and valuable guidance for personalized survival estimates and high-risk patient identification.

A Comparative Analysis of Laparoscopic Gastrectomy Versus Laparoscopic-Assisted Gastrectomy: The Overall and Disease-Free Survival

Gastric cancer remains a significant global health challenge with varied survival rates, emphasizing the need for research into effective surgical treatments. In this retrospective study, we compared the 72-month overall and disease-free survival between laparoscopic gastrectomy (LG) and laparoscopic-assisted gastrectomy (AG) in a cohort of 139 patients treated for gastric cancer. The analysis revealed that patients undergoing LG exhibited a significantly higher overall survival rate at 72 months compared to those undergoing AG. Although disease-free survival rates were comparable between the two groups, LG showed a marginal advantage. Subgroup analyses based on the type of gastrectomy and anastomosis demonstrated varied survival probabilities, with laparoscopic-assisted partial gastrectomy yielding the most favorable outcomes. These results highlight the importance of the choice of surgical technique in influencing survival outcomes in gastric cancer.

The role of postoperative neutrophil-to-lymphocyte ratio as a predictor of postoperative major complications following total gastrectomy for gastric cancer

Purpose

This study was performed to investigate the role of the perioperative neutrophil-to-lymphocyte ratio (NLR) as an early predictor of major postoperative complications after total gastrectomy for gastric cancer.

Methods

This single-center, retrospective study reviewed consecutive patients with gastric cancer who underwent total gastrectomy at a single institution from March 2009 to March 2021. The postoperative complications were graded according to the Clavien-Dindo classification. We analyzed the patient demographics and surgical outcomes according to the grade of postoperative complications in the major complications group (≥grade III) and the no major complications group (<grade III and no complication). Laboratory tests were performed preoperatively and on postoperative days (POD) 2 and 5 to determine the NLR.

Results

Out of 212 patients (mean age, 64.1 years; 152 male [71.7%]), 63 (29.7%) underwent minimally invasive surgery. Twenty-five (11.8%) were in the major complications group and 187 (88.2%) were in the no major complications group. There was a significant difference in the NLR on POD 2 (16.54 vs. 8.83, P = 0.033) between the 2 groups. According to the receiver operating characteristic curve for the NLR on POD 2, the cutoff was calculated to be 9.6. In multivariate analysis, an NLR on POD 2 of ≥9.6 and an American Society of Anesthesiologists physical status classification of ≥III were statistically significant predictors of major postoperative complications.

Conclusion

Determination of the NLR on POD 2 is a simple and useful method for the early prediction of major complications after total gastrectomy for gastric cancer.

Should Signet Ring Cell Histology Alter the Treatment Approach for Clinical Stage I Gastric Cancer?

BACKGROUND

Surgery alone is standard-of-care for stage I gastric adenocarcinoma; however, clinicians can offer preoperative therapy for clinical stage I disease with signet ring cell histology, given its presumed aggressive biology. We aimed to assess the validity of this practice.

METHODS

The National Cancer Database (2004-2015) was reviewed for patients with clinical stage I signet ring cell gastric adenocarcinoma who underwent treatment with surgery alone, perioperative chemotherapy, neoadjuvant therapy, or adjuvant therapy. Analysis was stratified by preoperative clinical/pathologic stage. Primary outcome was overall survival (OS).

RESULTS

Of 1018 patients, median age was 60 years (±14); 53% received surgery alone (n = 542), 5% received perioperative chemotherapy (n = 47), 12% received neoadjuvant therapy (n = 125), and 30% received adjuvant therapy (n = 304). For clinical stage I disease, surgery alone was associated with an improved 5-year OS rate (71%) versus perioperative chemotherapy (58%), neoadjuvant therapy (38%), or adjuvant therapy (52%) [overall p < 0.01]. For pathologic stage I, surgery alone had equivalent or improved survival compared with perioperative, neoadjuvant, and adjuvant therapy (5-year OS: 78% vs. 89% [p = 0.77] vs. 64% [p = 0.04] vs. 84% [p = 0.99]). Adjuvant therapy was associated with improved 5-year OS compared with pretreatment for those patients upstaged (37%) to pathologic stage II/III (55% vs. 36% and 34% vs. 7%; all p < 0.01).

CONCLUSIONS

This stage-specific study demonstrates improved survival with surgery alone for clinical stage I signet ring cell gastric adenocarcinoma. Despite 37% of clinical stage I patients being upstaged to pathologic stage II/III, adjuvant therapy offers a favorable rescue strategy, with improved outcomes compared with those treated preoperatively. Surgery alone also affords similar or improved survival for pathologic stage I disease versus multimodality therapy. This study challenges the bias to overtreat stage I signet ring cell gastric adenocarcinoma.

Association of serum levels of deoxyribose 1-phosphate and S-lactoylglutathione with neoadjuvant chemotherapy sensitivity in patients with gastric cancer: A metabolomics study

The present study screened serum samples from patients with advanced-stage gastric cancer and known sensitivities to neoadjuvant chemotherapy, in order to identify metabolites that may serve as potential biomarkers for chemotherapy sensitivity. A total of 47 patients with stage III (T4b) or IV gastric cancer, including 31 in the training group and 16 in a validation group, were classified based on their responses to conversion therapy consisting of oxaliplatin, tegafur and continuous hyperthermic peritoneal perfusion with cisplatin. Serum samples were analyzed by liquid chromatography-mass spectrometry to obtain a metabolite profile of each patient. Patients who were responsive and non-responsive to neoadjuvant chemotherapy exhibited significant differences in serum levels of deoxyribose 1-phosphate, S-lactoylglutathione, lysophosphatidylcholine (16:0) and O-arachidonoyl ethanolamine. Logistic regression analysis indicated that deoxyribose 1-phosphate and S-lactoylglutathione were independently associated with chemosensitivity. Serum levels of deoxyribose 1-phosphate and S-lactoylglutathione were independently associated with the sensitivity of gastric cancer to neoadjuvant chemotherapy, therefore, serving as potential predictors of patient response.

Safety of early oral feeding after total laparoscopic radical gastrectomy for gastric cancer (SOFTLY): Study protocol for a randomized controlled trial

BACKGROUND

Gastric cancer is the third most common cause of cancer-related deaths and has the fifth highest incidence worldwide, especially in eastern Asia, central and Eastern Europe, and South America. Currently, surgery is the only curative treatment for gastric cancer; however, there is an increasing trend toward laparoscopic radical gastrectomy. Early oral feeding (EOF) has been shown to benefit clinical outcomes compared with open gastrectomy under conditions of enhanced recovery after surgery. There are a lack of guidelines and evidence for the safety and feasibility of EOF in patients undergoing laparoscopic radical gastrectomy. Thus, a prospective randomized trial is warranted.

METHODS/DESIGN

The EOF after total laparoscopic radical gastrectomy (SOFTLY) study is a single-center, parallel-arm, non-inferiority randomized controlled trial which will enroll 200 patients who are pathologically diagnosed with gastric cancer and undergo laparoscopic radical gastrectomy. The primary endpoint, incidence of anastomotic leakage, is based on 1.9% in the control group in the CLASS-01 study. The patients will be randomized (1:1) into two groups: the EOF group will receive a clear liquid diet on post-operative day 1 (POD1) and the delayed oral feeding (DOF) group will receive a clear liquid diet on post-operative day 4 (POD4). The demographic and pathologic characteristics will be recorded. Total and oral nutritional intake, general data, total serum protein, serum albumin, blood glucose, and temperature will be recorded before surgery and at the time of hospitalization. Adverse events will also be recorded. The occurrence of post-operative fistulas, including anastomotic leakage, will be recorded as the main severe post-operative adverse event and represent the primary endpoint.

DISCUSSION

The safety and feasibility of EOF after gastrectomy has not been established. The SOFTLY trial will be the first randomized controlled trial involving total laparoscopic radical gastrectomy, in which the EOF group (POD1) will be compared with the DOF group (POD4). The results of the SOFTLY trial will provide data on the safety and feasibility of EOF after total laparoscopic radical gastrectomy.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR-IOR-15007660 . Registered on 28 December 2015. The study has full ethical and institutional approval.

Impact of spleen-preserving total gastrectomy on postoperative infectious complications and 5-year overall survival: systematic review and meta-analysis of contemporary randomized clinical trials

Background

The role of splenectomy in proximal gastric cancer is still debated. The objective of the present meta-analysis was to provide more-robust evidence about the effect of spleen-preserving total gastrectomy on postoperative infectious complications, overall morbidity, and 5-year overall survival (os).

Methods

PubMed, embase, and the Web of Science were consulted. Pooled effect measures were calculated using an inverse-variance weighted or Mantel-Haenszel in random effects meta-analysis. Heterogeneity was evaluated using I ² index and Cochran Q-test.

Results

Three randomized controlled trials published between 2000 and 2018 were included. Overall, 451 patients (50.1%) underwent open total gastrectomy with spleen preservation and 448 (49.9%) underwent open total gastrectomy with splenectomy. The patients ranged in age from 24 to 78 years. No differences were found in the number of harvested lymph nodes (p = 0.317), the reoperation rate (p = 0.871), or hospital length of stay (p = 0.347). The estimated pooled risk ratios for infectious complications, overall morbidity, and mortality were 1.53 [95% confidence interval (ci): 1.09 to 2.14; p = 0.016], 1.51 (95% ci: 1.11 to 2.05; p = 0.008), and 1.23 (95% ci: 0.40 to 3.71; p = 0.719) respectively. The estimated pooled hazard ratio for 5-year os was 1.06 (95% ci: 0.78 to 1.45; p = 0.707).

Conclusions

Spleen-preserving total gastrectomy should be considered in patients with curable gastric cancer because it is significantly associated with decreased postoperative infectious complications and overall morbidity, with no difference in the 5-year os. Those observations appear worthwhile for establishing better evidence-based treatment for gastric cancer.

Are the indications for postoperative radiotherapy in the NCCN guidelines for patients with gastric adenocarcinoma too broad? A study based on the SEER database

BACKGROUND

The types of patients with gastric adenocarcinoma (GA) for whom postoperative radiotherapy can improve the disease-specific survival rate (DSS) remain controversial. This study aims to explore the ideal indications.

METHODS

Patients in the Surveillance, Epidemiology, and End Results (SEER) database with T3-4Nx or TxN+ GA from January 1988 to December 2012 were included and divided into a postoperative chemoradiotherapy group (Group R) and a postoperative chemotherapy group (Group C). We established a nomogram to predict DSS and then divided entire patient cohort into low-risk and high-risk groups based on the DSS predicted by the nomogram.

RESULTS

The Cox multiple regression analysis demonstrated that various risk factors affected DSS for Group R. Based on these risk factors, a nomogram for predicting DSS was established. The decision curve indicated that the best clinical effect could be obtained when the threshold probability was 0-58%. The patients were then divided into low-risk (< 69 points) and high-risk (≥ 69 points) groups according to the five-year DSS predicted. DSS was significantly better for Group R than for Group C for high-risk patients (P < 0.001) but was similar for low-risk patients (P = 0.732).

CONCLUSION

At present, the National Comprehensive Cancer Network (NCCN) guidelines may include an overly broad range of indications for postoperative radiotherapy for patients with GA. For intestinal GA patients with a postoperative pathologic stage of T1 N1 who are younger than 65 years, have had more than 15 lymph nodes dissected, and have received postoperative chemotherapy, postoperative radiotherapy should not be recommended.

Approaches and genetic determinants in predicting response to neoadjuvant chemotherapy in locally advanced gastric cancer

Gastric cancer remains a major health burden worldwide. There is near-universal agreement that neoadjuvant chemotherapy (NAC) is a preferred management for locally advanced gastric cancer (LAGC). However, the optimal approach for an individual patient is still not clear and remains controversial, which could be at least partly explained by the lack of predictive tools. The ability to predict chemosensitivity from NAC in routine clinical practice is difficult and is an area of intense investigation, especially in the Precision-Medicine Era. Available consistent evidence suggests that a favorable tumor histopathological response to NAC may be a useful positive prognostic marker in gastric cancer. Hence, it is reasonable to speculate that making the histopathological response from NAC predictable will dramatically facility the NAC and improve patients' outcome. This review provides an overview on the current status of predictive biomarkers for histopathological response from NAC in LAGC, including clinicopathological variables, imaging and molecular testing. Furthermore, limitations and future perspectives are also discussed.

Development and external validation of preoperative risk models for operative morbidities after total gastrectomy using a Japanese web-based nationwide registry

BACKGROUND

Total gastrectomy is a relatively difficult and invasive procedure among gastrointestinal surgeries, and major morbidities following total gastrectomy can be serious and fatal. This study aimed to develop and validate preoperative risk models of morbidities associated with total gastrectomy using a Japanese web-based nationwide registry.

METHODS

The national clinical database was used to retrieve the records of 39,253 patients who underwent total gastrectomy in 1,841 hospitals between January 1, 2011 and December 31, 2012.

RESULTS

Mean patient age was 69.1 years, and 73.8% of the patients were male. The overall morbidity rate was 21.5%, which included 8.1% with surgical site infection (SSI), 4.5% with anastomotic leak, 5.0% with pancreatic fistula, 3.7% with pneumonia, 1.9% with prolonged ventilation, and 1.2% with renal failure. Sex, splenectomy, and Brinkman index were selected as common risk factors for SSI, anastomotic leak, and pancreatic fistula. Pancreatectomy was the most significant preoperative risk factor in the risk model of SSI and pancreatic fistula. Need of assistance with activities of daily living, chronic obstructive pulmonary disease, previous cerebrovascular disease, American Society of Anesthesiologists score class 3 and over, presence of esophageal cancer, and body mass index more than 25 were selected as common risk factors for pneumonia, prolonged ventilation over 48 h, and renal failure.

CONCLUSIONS

We have created the first reported risk models of morbidities associated with total gastrectomy, using a Japanese nationwide database. The risk models developed in this study may be useful to preoperatively predict operative morbidities in patients undergoing total gastrectomy.

Role of histological regression grade after two neoadjuvant approaches with or without radiotherapy in locally advanced gastric cancer

Background:

The degree of histopathological response after neoadjuvant therapy in locally advanced gastric cancer (GC) is a key determinant of patients' long-term outcome. We aimed to assess the pattern of histopathological regression after two neoadjuvant approaches and its impact on survival times.

Methods:

Regression grade of the primary tumour (Becker criteria) and the degree of nodal response by a 4-point scale (grades A–D) were assessed. Grade A—true negative lymph nodes (LNs); grade B and C—infiltrated LNs with any or little evidence of nodal response; and grade D—complete pathological response in a previously infiltrated LN. A favourable pathological response was defined as Becker Ia–b and grade D.

Results:

From 2004 to 2014, 80 patients with GC (cT3–4/N+ by CT-scan/EUS) were treated with either preoperative chemotherapy (ChT, n=34) or chemoradiation (CRT, n=46). Patients in the CRT group had a higher likelihood of achieving a Becker Ia–b response (58 vs 32%, P=0.001), a grade D nodal regression (30 vs 6%, P=0.009) and a favourable pathological response (23 vs 3% P=0.019). Patients with a grade D nodal response had a longer 5-year PFS and OS compared with those with a grade B or C response. Patients with a baseline negative LN status had similar outcomes irrespective of the preoperative therapy received (5-year OS; ChT vs CRT, 58 vs 51%, P=0.92).

Conclusions:

Preoperative chemoradiation increases the likelihood of achieving favourable histopathological features that correlate with a 5-year OS>70% in GC patients.

Gastric cancer: Current status of lymph node dissection

D2 procedure has been accepted in Far East as the standard treatment for both early (EGC) and advanced gastric cancer (AGC) for many decades. Recently EGC has been successfully treated with endoscopy by endoscopic mucosal resection or endoscopic submucosal dissection, when restricted or extended Gotoda's criteria can be applied and D1+ surgery is offered only to patients not fitted for less invasive treatment. Furthermore, two randomised controlled trials (RCTs) have been demonstrating the non inferiority of minimally invasive technique as compared to standard open surgery for the treatment of early cases and recently the feasibility of adequate D1+ dissection has been demonstrated also for the robot assisted technique. In case of AGC the debate on the extent of nodal dissection has been open for many decades. While D2 gastrectomy was performed as the standard procedure in eastern countries, mostly based on observational and retrospective studies, in the west the Medical Research Council (MRC), Dutch and Italian RCTs have been conducted to show a survival benefit of D2 over D1 with evidence based medicine. Unfortunately both the MRC and the Dutch trials failed to show a survival benefit after the D2 procedure, mostly due to the significant increase of postoperative morbidity and mortality, which was referred to splenopancreatectomy. Only 15 years after the conclusion of its accrual, the Dutch trial could report a significant decrease of recurrence after D2 procedure. Recently the long term survival analysis of the Italian RCT could demonstrate a benefit for patients with positive nodes treated with D2 gastrectomy without splenopancreatectomy. As nowadays also in western countries D2 procedure can be done safely with pancreas preserving technique and without preventive splenectomy, it has been suggested in several national guidelines as the recommended procedure for patients with AGC.

Histological evaluation for chemotherapeutic responses of metastatic lymph nodes in gastric cancer

AIM: To investigate the effect of preoperative chemotherapy (pre-CTx) for metastatic lymph nodes (MLNs) of gastric cancer (GC).

METHODS: A retrospective cohort of patients with advanced GC, who underwent pre-CTx followed by gastrectomy, was reviewed. The histological tumor regression grade (TRG), which considered the percentage of residual cancer in the visible tumor bed, was applied to primary tumors and individual MLNs: G1a (complete response), G1b (< 10%), G2 (10%-50%) and G3 (> 50%). The clinical response to pre-CTx was retrospectively evaluated using only MLNs information, and we compared the histological and clinical evaluations of MLNs.

RESULTS: Twenty-eight patients were enrolled. A total of 438 MLNs were retrieved, and 22 (5%), 48 (11%), 63 (14%) and 305 (70%) LNs were assigned as G1a, G1b, G2 and G3, respectively. Stratification of the residual MLNs based on the TRGs was as follows: 28 G1b MLNs (9%), 48 G2 MLNs (15%), and 253 G3 MLNs (76%) in the D1 region; 20 (23%), 15 (17%), and 52 (60%) in the D2 region, respectively. However, no significant correlation was found between TRGs in MLNs and clinical response in the subgroup for which evaluation of clinical response was available.

CONCLUSION: Pre-CTx does not provide any outstanding histological benefit for MLNs, and an appropriate D2 lymphadenectomy should routinely be performed to offer the chance of curative resection.

FV-429 Induced Apoptosis Through ROS-Mediated ERK2 Nuclear Translocation and p53 Activation in Gastric Cancer Cells

Following our previous finding which revealed that FV-429 induces apoptosis in human hepatocellular carcinoma HepG2 cells, in this study, we found that FV-429 could also induce apoptosis in human gastric cancer cells. Firstly, FV-429 inhibited the viability of BGC-823 and MGC-803 cells with IC50 values in the range of 38.10 ± 6.28 and 31.53 ± 6.84 µM for 24 h treatment by MTT-assay. Secondly, FV-429 induced apoptosis in BGC-823 and MGC-803 cells through the mitochondrial-mediated pathway, showing an increase in Bax/Bcl-2 ratios, and caspase-9 activation, without change in caspase-8. Further research revealed that the mitogen-activated protein kinases, including c-Jun N-terminal kinase, extracellular regulated kinase, and p38 mitogen-activated protein kinase, could be activated by FV-429-induced high level ROS. Moreover, FV-429 also promoted the ERK2 nuclear translocation, resulting in the co-translocation of p53 to the nucleus and increased transcription of p53-regulated proapoptotic genes. FV-429 significantly inhibited the nude mice xenograft tumors growth of BGC-823 or MGC-803 cells in vivo.

Multimodal treatment of gastric cancer in the west: Where are we going?

The incidence of gastric cancer (GC) is decreasing worldwide, especially for intestinal histotype of the distal third of the stomach. On the contrary, proximal location and diffuse Lauren histotype have been reported to be generally stable over time. In the west, no clear improvement in long-term results was observed in clinical and population-based studies. Results of treatment in these neoplasms are strictly dependent on tumor stage. Adequate surgery and extended lymphadenectomy are associated with good long-term outcome in early-stage cancer; however, results are still unsatisfactory for advanced stages (III and IV), for which additional treatments could provide a survival benefit. This implies a tailored approach to GC. The aim of this review was to summarize the main multimodal treatment options in advanced resectable GC. Perioperative or postoperative treatments, including chemotherapy, chemoradiotherapy, targeted therapies, and hyperthermic intraperitoneal chemotherapy have been reviewed, and the main ongoing and completed trials have been analyzed. An original tailored multimodal approach to non-cardia GC has been also proposed.

[Volumes of lymphadenectomy in gastric cancer surgery]

It is summarized an experience of 1528 resections for gastric cancer supplemented by D1-, D2-, D2,5- and D3-lymphadenectomy in 751, 241, 359 and 177 patients resrectively. Unconventional type D2.5 means D2-lymphodis section with additional lymphadenectomy along hepatoduodenal ligament and superior retropancreatic nodes as well as omental bursa removal with lymphodis section of esophageal opening crura. Analysis of immediate and remote results is presented. It is concluded that D3-lymphadenectomy is minimally preferred over D2.5-type in gastric cancer staging. D3-lymphodis section has the largest number of especially purulent and pancreatogenic postoperative complications. D2.5-lymphadenectomy significantly increases 5-year survival in comparison with D2-lymphodis section (from 51.2 ± 4.9 to 64.0 ± 4.1%; p<0.001) and may be chosen for any radical surgery for gastric cancer including early forms. Localized proximal tumors which are in distinctive for metastasis into hepatoduodenal ligament lymph nodes are exception. D3-lymphodis section did not impact on survival in comparison with D2,5-lymphadenectomy. Only patients with antral cancer after distal subtotal gastric resection had 5-year survival increasing on 8 % (from 60.6 ± 7.5 to 68.5 ± 6.3%).

CO-029 is overexpressed in gastric cancer and mediates the effects of EGF on gastric cancer cell proliferation and invasion

Tetraspanins are cell-surface glycoproteins and have received attention recently as both suppressors and promoters of metastasis. CO-029 is a member of the tetraspanin family and is implicated to be a metastasis-promoting tetraspanin in some cancers. However, the role of CO-029 in gastric cancer remains unexplored. The present study aimed to investigate the expression of CO-029 in gastric cancer tissues and to determine whether CO-029 is involved in the effects of epidermal growth factor (EGF) on gastric cancer cell proliferation and invasion. We collected clinical samples and found that the expression of CO-029 was increased both at the mRNA level and protein level in gastric cancer tissues in comparison to normal and tumor-adjacent tissues, as demonstrated by RT-qPCR and western blot analysis, respectively. Furthermore, we performed an in vitro experiment using AGS cells and observed that EGF promoted AGS cell proliferation and enhanced the invasion ability of the AGS cells, as shown by MTT assay and cell invasion assay, respectively. To the best of our knowledge, our results reveal for the first time, that CO-029 expression was affected by EGF in a concentration- time-dependent manner. The knockdown of CO-029 attenuated the effects of EGF on gastric cancer cell proliferation and invasion. These findings suggest that CO-029 is an oncogene in human gastric cancer and that CO-029 at least partially mediates the effects of EGF on gastric cancer cell proliferation and invasion. Our data may provide a novel target for therapeutic intervention in human gastric cancer.

Total gastrectomy risk model: data from 20,011 Japanese patients in a nationwide internet-based database

OBJECTIVE

To construct a risk model for total gastrectomy outcomes using a nationwide Internet-based database.

BACKGROUND

Total gastrectomy is a very common procedure in Japan. This procedure is among the most invasive gastrointestinal procedures and is known to carry substantial surgical risks.

METHODS

The National Clinical Database was used to retrieve records on more than 1,200,000 surgical cases from 3500 hospitals in 2011. After data cleanup, 20,011 records from 1623 hospitals were analyzed for procedures performed between January 1, 2011, and December 31, 2011.

RESULTS

The average patient age was 68.9 years; 73.7% were male. The overall morbidity was 26.2%, with a 30-day mortality rate of 0.9%, in-hospital mortality rate of 2.2%, and overall operative mortality rate of 2.3%. The odds ratios for 30-day mortality were as follows: ASA (American Society of Anesthesiologists) grade 4 or 5, 9.4; preoperative dialysis requirement, 3.9; and platelet count less than 50,000 per microliter, 3.1. The odds ratios for operative mortality were as follows: ASA grade 4 or 5, 5.2; disseminated cancer, 3.5; and alkaline phosphatase level of more than 600 IU/L, 3.1. The C-index of 30-day mortality and operative mortality was 0.811 (95% confidence interval [CI], 0.744-0.879) and 0.824 (95% CI, 0.781-0.866), respectively.

CONCLUSIONS

We have performed the first reported risk stratification study for total gastrectomy, using a nationwide Internet-based database. The total gastrectomy outcomes in the nationwide population were satisfactory. The risk models that we have created will help improve the quality of surgical practice.

Adjuvant and/or neoadjuvant therapy for gastric cancer? A perspective review

Surgery is still the only curative therapy for locoregional gastric cancer. Hereby it is important to achieve negative margins (R0 resection) and to perform an adequate lymph-node dissection (D2 lymphadenectomy). Unfortunately most cases of gastric cancer are diagnosed in a locally advanced tumor stage. The poor prognosis of patients with these tumors is due to the frequent recurrences after primary resection in curative intent. This observation led to the development of (neo)adjuvant treatment concepts. Beginning with the end of the 1980s, more and more patients with locally advanced tumors were subjected to a preoperative, perioperative, or postoperative treatment in order to improve the prognosis after curative resection. However, in different regions of the world, different regiments are preferred. While adjuvant chemotherapy is the established treatment in Asia, adjuvant chemoradiotherapy is favored in the USA and perioperative chemotherapy is considered the treatment of choice in Europe. However, recently a certain convergence of the different philosophies is to be observed. This article covers the relevant studies dealing with neoadjuvant and adjuvant treatment concepts and gives an overview on the latest developments in this field.

Preliminary study of surgical audit for overall survival following gastric cancer resection

BACKGROUND

Previous studies for surgical audit have focused on short-term outcomes, such as perioperative mortality. There has been no gold standard how to evaluate quality of care for long-term outcomes in surgical oncology. This preliminary study aims to propose a method for surgical audit targeting long-term outcome following gastrectomy for gastric cancer.

METHODS

We prospectively investigated a set of variables relating to physiologic conditions, tumor characteristics and operations in patients who underwent gastrectomy for gastric cancer between June 2005 and July 2008 in 18 referral hospitals in Japan. Overall survival (OS) is the endpoint. Cox hazard regression analysis was used to generate a model to predict OS. The calibration and discrimination power of the model were assessed using the Hosmer-Lemeshow (H-L) test and area under the receiver-operating characteristic curve (AUC), respectively. The ratio of observed-to-estimated 5-year OS rates (OE ratio) was defined as a measure of quality.

RESULTS

Among 762 patients analyzed, 697 (91%) completed the 5-year follow-up. The constructed model for OS exhibited a good discrimination power (AUC, 95% confidence interval 0.89, 0.86-0.91), which was significantly better than that for the UICC stage (0.81, 0.77-0.84). This model also demonstrated a good calibration power (H-L: χ(2) = 27.2, df = 8, P = 0.77). The OE ratios among the participating hospitals revealed no significant variation between 0.74 and 1.1.

CONCLUSIONS

The current study suggests the possibility of surgical audit for postoperative OS in gastric cancer. Further studies including high-volume centers will be necessary to validate this idea.

Problems faced by evidence-based medicine in evaluating lymphadenectomy for gastric cancer

Gastric cancer surgical management differs between Eastern Asia and Western countries. Extended lymphadenectomy (D2) is the standard of care in Japan and South Korea since decades, while the majority of United States patients receive at most a limited lymphadenectomy (D1). United States and Northern Europe are considered the scientific leaders in medicine and evidence-based procedures are the cornerstone of their clinical practice. However, surgeons in Eastern Asia are more experienced, as there are more new cases of gastric cancer in Japan (107898 in 2012) than in the entire European Union (81592), or in South Korea (31269) than in the entire United States (21155). For quite a long time evidence-based medicine (EBM) did not solve the question whether D2 improves long-term prognosis with respect to D1. Indeed, eastern surgeons were reluctant to perform D1 even in the frame of a clinical trial, as their patients had a very good prognosis after D2. Evidence-based surgical indications provided by Western trials were questioned, as surgical procedures could not be properly standardized. In the present study we analyzed indications about the optimal extension of lymphadenectomy in gastric cancer according to current scientific literature (2008-2012) and surgical guidelines. We searched PubMed for papers using the key words “lymphadenectomy or D1 or D2” AND “gastric cancer” from 2008 to 2012. Moreover, we reviewed national guidelines for gastric cancer management. The support to D2 lymphadenectomy increased progressively from 2008 to 2012: since 2010 papers supporting D2 have achieved a higher overall impact factor than the other papers. Till 2011, D2 was the procedure of choice according to experts’ opinion, while three meta-analyses found no survival advantage after D2 with respect to D1. In 2012-2013, however, two meta-analyses reported that D2 improves prognosis with respect to D1. D2 lymphadenectomy was proposed as the standard of care for advanced gastric cancer by Japanese National Guidelines since 1981 and was adopted as the standard procedure by the Italian Research Group for Gastric Cancer since the Nineties. D2 is now indicated as the standard of surgical treatment with curative intent by the German, British and ESMO-ESSO-ESTRO guidelines. At variance American NCCN guidelines recommend a D1⁺ or a modified D2 lymph node dissection. In conclusion, D2 lymphadenectomy, originally developed by Eastern surgeons, is now becoming the procedure of choice also in the West. In gastric cancer surgery EBM is lagging behind national guidelines, rather than preceding and orienting them. To eliminate this lag, EBM should value to a larger extent Eastern Asian literature and should evaluate not only the quality of the study design but also the quality of surgical procedures.

Neoadjuvant chemotherapy followed by surgery versus surgery alone for gastric carcinoma: systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The effect of neoadjuvant chemotherapy (NAC) on Gastric carcinoma (GC) has been extensively studied, while its survival and surgical benefits remain controversial. This study aims to perform a meta-analysis of high-quality randomized controlled trials (RCTs), comparing efficacy, safety and other outcomes of NAC followed by surgery with surgery alone (SA) for GC.

METHODS

We systematically searched databases of MEDLINE, EMBASE, The Cochrane Library and Springer for RCTs comparing NAC with SA when treating GC. Reference lists of relevant articles and reviews, conference proceedings and ongoing trial databases were also searched. Primary outcomes were 3-year and 5-year survival rates, survival time, and total and perioperative mortalities. Secondary outcomes included down-staging effects, R0 resection rate, and postoperative complications. Meta-analysis was conducted where possible comparing items using relative risks (RRs) and weighted mean differences (WMDs) according to type of data. NAC-related objective response, safety and toxicity were also specifically analyzed.

RESULTS

A total of 9 RCTs comparing NAC (n = 511) with SA (n = 545) published from 1995 to 2010 were identified. SA tended to be accompanied with higher overall mortality rate than NAC (46.03% vs 40.61%, RR: 0.83, 95% CI: 0.65-1.06, P = 0.14). Significantly, higher incidence of cases without regional lymph node metastasis observed upon resection were achieved among patients receiving NAC than those undergoing SA (25.68% vs 16.95%, RR: 1.92, 95% CI: 1.20-3.06, P = 0.006). All other parameters were comparable. Of the evaluable patients, 43.0% demonstrated either complete or partial response. The comprehensive NAC-related side-effect rate was 18.2% among patients available for safety assessment.

CONCLUSIONS

NAC contributes to lowering nodal stages, and potentially reduces overall mortality. Response rate may be an important influential factor impacting advantages, with chemotherapy-related adverse effects as a drawback. This level 1a evidence doesn't support NAC to outweigh SA in terms of survival and surgical benefits when dealing with GC.

Neoadjuvant chemotherapy followed by surgery versus surgery alone for gastric carcinoma: systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The effect of neoadjuvant chemotherapy (NAC) on Gastric carcinoma (GC) has been extensively studied, while its survival and surgical benefits remain controversial. This study aims to perform a meta-analysis of high-quality randomized controlled trials (RCTs), comparing efficacy, safety and other outcomes of NAC followed by surgery with surgery alone (SA) for GC.

METHODS

We systematically searched databases of MEDLINE, EMBASE, The Cochrane Library and Springer for RCTs comparing NAC with SA when treating GC. Reference lists of relevant articles and reviews, conference proceedings and ongoing trial databases were also searched. Primary outcomes were 3-year and 5-year survival rates, survival time, and total and perioperative mortalities. Secondary outcomes included down-staging effects, R0 resection rate, and postoperative complications. Meta-analysis was conducted where possible comparing items using relative risks (RRs) and weighted mean differences (WMDs) according to type of data. NAC-related objective response, safety and toxicity were also specifically analyzed.

RESULTS

A total of 9 RCTs comparing NAC (n = 511) with SA (n = 545) published from 1995 to 2010 were identified. SA tended to be accompanied with higher overall mortality rate than NAC (46.03% vs 40.61%, RR: 0.83, 95% CI: 0.65-1.06, P = 0.14). Significantly, higher incidence of cases without regional lymph node metastasis observed upon resection were achieved among patients receiving NAC than those undergoing SA (25.68% vs 16.95%, RR: 1.92, 95% CI: 1.20-3.06, P = 0.006). All other parameters were comparable. Of the evaluable patients, 43.0% demonstrated either complete or partial response. The comprehensive NAC-related side-effect rate was 18.2% among patients available for safety assessment.

CONCLUSIONS

NAC contributes to lowering nodal stages, and potentially reduces overall mortality. Response rate may be an important influential factor impacting advantages, with chemotherapy-related adverse effects as a drawback. This level 1a evidence doesn't support NAC to outweigh SA in terms of survival and surgical benefits when dealing with GC.

Changes of quality of life after gastric tube reconstruction in adenocarcinoma of the esophagogastric junction

Objective: To investigate changes of quality of life (QOL) of patients with adenocarcinoma of the esophagogastric junction (AEG) after gastric tube anastomosis.

Methods: From January 2009 to December 2011, eighty-seven patients with Types II and III AEG were selected for gastric tube reconstruction after proximal gastrectomy. The QOL of the patients was assessed using the Chinese versions of the EORTC QLQ-C30 and the EORTC QLQ-STO22 preoperatively, as well as one and two years postoperatively.

Results: The QLQ-C30 showed that the global health of the respondents decreased at one year after the surgery (P=0.02). The preoperative score for physical function was significantly better than the one- and two-year post-operation scores. The preoperative scores for pain, nausea and vomiting, and economic difficulties were worse than the one- and two-year post-operation scores (P<0.05). Diarrhea was worse at one year post-operation than during pre-operation (P = 0.00), but improved at two years after the operation. The QLQ-STO22 scales showed that the preoperative dysphagia score was better than one-year post-operation, and no significant differences were observed in terms of dysphagia between the pre-operation and two-year postoperative periods. Preoperative reflux and taste scores were better than those after the operation (P<0.05). The hair loss score at one-year post-operation was worse than at either pre-operation or two-year post-operation.

Conclusions: Most QOL scales worsened after surgery, particularly at postoperative year one. However, the scales can be gradually recovered to preoperative levels. The physical function, nausea and vomiting, reflux, taste, and financial difficulties did not fully recover two years after the operation.

Peritoneal carcinomatosis

Several gastrointestinal and gynecological malignancies have the potential to disseminate and grow in the peritoneal cavity. The occurrence of peritoneal carcinomatosis (PC) has been shown to significantly decrease overall survival in patients with liver and/or extraperitoneal metastases from gastrointestinal cancer. During the last three decades, the understanding of the biology and pathways of dissemination of tumors with intraperitoneal spread, and the understanding of the protective function of the peritoneal barrier against tumoral seeding, has prompted the concept that PC is a loco-regional disease: in absence of other systemic metastases, multimodal approaches combining aggressive cytoreductive surgery, intraperitoneal hyperthermic chemotherapy and systemic chemotherapy have been proposed and are actually considered promising methods to improve loco-regional control of the disease, and ultimately to increase survival. The aim of this review article is to present the evidence on treatment of PC in different tumors, in order to provide patients with a proper surgical and multidisciplinary treatment focused on optimal control of their locoregional disease.

Adjuvant treatment for gastric cancer: chemotherapy versus radiation

Gastric cancer is among the leading causes of cancer death worldwide. Surgery is the only curative modality, but mortality remains high because a significant number of patients have recurrence after complete surgical resection. Chemotherapy, radiation, and chemoradiotherapy have all been studied in an attempt to reduce the risk for relapse and improve survival. There is no globally accepted standard of care for resectable gastric cancer, and treatment strategies vary across the world. Postoperative chemoradiation with 5-fluorouracil/leucovorin is most commonly practiced in the United States; however, recent clinical trials from Asia have shown benefit of adjuvant chemotherapy alone and have questioned the role of radiation. In this review, we examine the current literature on adjuvant treatment of gastric cancer and discuss the roles of radiation and chemotherapy, particularly in light of these new data and their applicability to the Western population. We highlight some of the ongoing and planned clinical trials in resectable gastric cancer and identify future directions as well as areas where further research is needed.

Neoadjuvant treatment for gastric cancer

Surgery is still considered to be the mainstay for the treatment of localized gastric cancer with negative margins (R0-resection) and an adequate lymph-node-dissection (D2-lymphadenectomy). Unfortunately, most cases of gastric cancer are only diagnosed at an advanced stage due to frequent recurrences after primary resection in curative intent. In order to improve prognosis after curative resection, in the recent past, patients with locally advanced tumors were subjected to a pre-, peri-, or postoperative treatment. Interestingly, postoperative chemotherapy has significantly improved survival after gastric resection in Asia, adjuvant radiochemotherapy is favored in North America and perioperative chemotherapy is considered as a treatment of choice in Europe indicating region specific approach towards the treatment. Recently there has also been growing evidence of positive outcomes of neoadjuvant radiochemotherapy on patient survival. In the present article, we discuss the concepts of neoadjuvant treatment approach and provide recommendations to surgeons based on current evidence.

Neoadjuvant treatment for gastric cancer

Surgery is still considered to be the mainstay for the treatment of localized gastric cancer with negative margins (R0-resection) and an adequate lymph-node-dissection (D2-lymphadenectomy). Unfortunately, most cases of gastric cancer are only diagnosed at an advanced stage due to frequent recurrences after primary resection in curative intent. In order to improve prognosis after curative resection, in the recent past, patients with locally advanced tumors were subjected to a pre-, peri-, or postoperative treatment. Interestingly, postoperative chemotherapy has significantly improved survival after gastric resection in Asia, adjuvant radiochemotherapy is favored in North America and perioperative chemotherapy is considered as a treatment of choice in Europe indicating region specific approach towards the treatment. Recently there has also been growing evidence of positive outcomes of neoadjuvant radiochemotherapy on patient survival. In the present article, we discuss the concepts of neoadjuvant treatment approach and provide recommendations to surgeons based on current evidence.

IL-26 promotes the proliferation and survival of human gastric cancer cells by regulating the balance of STAT1 and STAT3 activation

Interleukin-26 (IL-26) is one of the cytokines secreted by Th17 cells whose role in human tumors remains unknown. Here, we investigated the expression and potential role of IL-26 in human gastric cancer (GC). The expression of IL-26 and related molecules such as IL-20R1, STAT1 and STAT3 was examined by real-time PCR and immunohistochemisty. The effects of IL-26 on cell proliferation and cisplatin-induced apoptosis were analyzed by BrdU cooperation assay and PI-Annexin V co-staining, respectively. Lentiviral mediated siRNA was used to explore its mechanism of action, and IL-26 related signaling was analyzed by western blotting. Human GC tissues showed increased levels of IL-26 and its related molecules and activation of STAT3 signaling, whereas STAT1 activation did not differ significantly between GC and normal gastric tissues. Moreover, IL-26 was primarily produced by Th17 and NK cells. IL-26 promoted the proliferation and survival of MKN45 and SGC-7901 gastric cancer cells in a dose-dependent manner. Furthermore, IL-20R2 and IL-10R1, which are two essential receptors for IL-26 signaling, were expressed in both cell lines. IL-26 activated STAT1 and STAT3 signaling; however, the upregulation of the expression of Bcl-2, Bcl-xl and c-myc indicated that the effect of IL-26 is mediated by STAT3 activation. Knockdown of STAT1 and STAT3 expression suggested that the proliferative and anti-apoptotic effects of IL-26 are mediated by the modulation of STAT1/STAT3 activation. In summary, elevated levels of IL-26 in human GC promote proliferation and survival by modulating STAT1/STAT3 signaling.

Effectiveness of 5-flurouracil-based neoadjuvant chemotherapy in locally-advanced gastric/gastroesophageal cancer: A meta-analysis

AIM: To investigate the effectiveness of 5-flurouracil-based neoadjuvant chemotherapy (NAC) for gastroesophageal and gastric cancer by meta-analysis.

METHODS: MEDLINE and manual searches were performed to identify all published randomized controlled trials (RCTs) investigating the efficacy of the flurouracil-based NAC for gastroesophageal and gastric cancer, and RCTs of NAC for advanced gastroesophageal and gastric cancer vs no therapy before surgery. Studies that included patients with metastases at enrollment were excluded. Primary endpoint was the odds ratio (OR) for improving overall survival rate of patients with gastroesophageal and gastric cancer. Secondary endpoints were the OR of efficiency for down-staging tumor and increasing R0 resection in patients with gastroesophageal and gastric cancer. Safety analyses were also performed. The OR was the principal measurement of effect, which was calculated as the treatment group (NAC plus surgery) vs control group (surgery alone) and was presented as a point estimate with 95% confidence intervals (CI). All calculations and statistical tests were performed using RevMan 5.1 software.

RESULTS: Seven RCTs were included for the analysis. A total of 1249 patients with advanced gastroesophageal and gastric cancer enrolled in the seven trials were divided into treatment group (n = 620) and control group (n = 629). The quality scores of the RCTs were assessed according to the method of Jadad. The RCT quality scores ranged from 2 to 7 (5-point scale), with a mean of 3.75. The median follow-up time in these studies was over 3 years. The meta-analysis showed that NAC improved the overall survival rate (OR 1.40, 95%CI 1.11-1.76; P = 0.005), which was statistically significant. The 3-year progression-free survival rate was significantly higher in treatment group than in control group (37.7% vs 27.3%) (OR 1.62, 95%CI 1.21-2.15; P = 0.001). The tumor down-stage rate was higher in treatment group than in control group (55.76% vs 41.38%) (OR 1.77, 95%CI 1.27-2.49; P = 0.0009) and the R0 resection rate of the gastroesophageal and gastric cancer was higher in treatment group than in control group (75.11% vs 68.56%) (OR 1.38, 95%CI 1.03-1.85; P = 0.03), with significant differences. No obvious safety concerns about mortality and complications were raised in these trials. There were no statistically significant differences in perioperative mortality (5.08% vs 4.86%) (OR 1.05, 95%CI 0.57-1.94; P = 0.87 fixed-effect model) and in the complication rate between the two groups (13.25% vs 9.66%) (OR 1.40, 95%CI 0.91-2.14; P = 0.12 fixed-effect model). Trials showed that patients from Western countries favored NAC compared with those from Asian countries (OR 1.40, 95%CI 1.07-1.83). Monotherapy was inferior to multiple chemotherapy (OR 1.40, 95%CI 1.07-1.83). Intravenous administration of NAC was more advantageous than oral route (OR 1.41, 95%CI 1.09-1.81).

CONCLUSION: Flurouracil-based NAC can safely improve overall survival rate of patients with gastroesophageal/gastric cancer. Additionally, NAC can down the tumor stage and improve R0 resection.

Totally laparoscopic versus open gastrectomy for gastric cancer: a matched cohort study

BACKGROUND

The role of laparoscopic surgery for the treatment of gastric cancer is still controversial, particularly in terms of oncologic efficacy. The aim of this study was to compare short-term outcomes of laparoscopic and open resection for gastric cancer at a single Western institution.

SUBJECTS AND METHODS

This study was designed as a matched cohort study from a prospective gastric cancer database. Forty-one patients undergoing laparoscopic gastrectomy for gastric cancer between June 2008 and January 2012 were matched with 41 patients undergoing open gastrectomy in the same time period. Patient pairing was done according to age, gender, type of gastrectomy (subtotal or total), and tumor stage via a randomized statistical method. The short-term outcomes and oncologic adequacy of the laparoscopic and open procedures were compared. A D2 lymph node dissection was performed in the majority of patients in both groups.

RESULTS

The two study groups were similar with respect to patient and tumor characteristics. Laparoscopic procedures were associated with a decreased blood loss (118.7 versus 312.4 mL, P<.005), incidence of surgery-unrelated complications (3 versus 9 patients, P<.05), and duration of hospital stay (8.1 versus 11.5 days, P<.05) but increased operative time for both subtotal (223.5 versus 158.2 minutes, P<.001) and total (298.1 versus 185.5 minutes, P<.001) gastrectomies. The mean number of retrieved lymph nodes after D2 dissection was similar: 30.0 for laparoscopic and 29.7 for open patients.

CONCLUSIONS

Within the limitations of a nonrandomized analysis, this study shows that the laparoscopic approach is a safe and oncologically adequate option for the treatment of gastric cancer, which compares favorably with open gastrectomy in short-term outcomes.

Patient optimization for gastrointestinal cancer surgery

BACKGROUND

Although surgical resection remains the central element in curative treatment of gastrointestinal cancer, increasing emphasis and resource has been focused on neoadjuvant or adjuvant therapy. Developments in these modalities have improved outcomes, but far less attention has been paid to improving oncological outcomes through optimization of perioperative care.

METHODS

A narrative review is presented based on available and updated literature in English and the authors' experience with enhanced recovery research.

RESULTS

A range of perioperative factors (such as lifestyle, co-morbidity, anaemia, sarcopenia, medications, regional analgesia and minimal access surgery) are modifiable, and can be optimized to reduce short- and long-term morbidity and mortality, improve functional capacity and quality of life, and possibly improve oncological outcome. The effect on cancer-free and overall survival may be of equal magnitude to that achieved by many adjuvant oncological regimens. Modulation of core factors, such as nutritional status, systemic inflammation, and surgical and disease-mediated stress, probably influences the host's immune surveillance and defence status both directly and through reduced postoperative morbidity.

CONCLUSION

A wider view on long-term effects of expanded or targeted enhanced recovery protocols is warranted.

Laparoscopic gastrectomy for cancer

Gastric cancer is common worldwide. Tumor location and disease stage differ between Asian and Western countries. Western patients often have higher BMIs and comorbidities that may make laparoscopic resections challenging. Multiple trials from Asian countries demonstrate the benefits of laparoscopic gastrectomy for early gastric cancer while maintaining equivalent short-term and long-term oncologic outcomes compared with open surgery. The outcomes of laparoscopy seem to offer equivalent results to open surgery. In the United States, laparoscopic gastrectomy remains in its infancy and is somewhat controversial. This article summarizes the literature on the epidemiology, operative considerations and approaches, and outcomes for laparoscopic gastrectomy.

A phase II trial of ixabepilone in Asian patients with advanced gastric cancer previously treated with fluoropyrimidine-based chemotherapy

PURPOSE

The highest rates of gastric cancer occur in Eastern Asia. Fluoropyrimidine-based therapy is used initially in unresectable and metastatic disease, but no single standard of care exists following disease progression. Ixabepilone, an epothilone B analog, is a non-taxane microtubule-stabilizing agent with clinical activity across multiple tumor types approved by the United States Food and Drug Administration for treatment of metastatic breast cancer.

METHODS

Asian patients with unresectable or metastatic gastric adenocarcinoma who had failed fluoropyrimidine-based chemotherapy received ixabepilone 40 mg/m(2) by 3-h intravenous infusion every 3 weeks. The primary endpoint was objective response rate (ORR).

RESULTS

Fifty-two patients were treated (65.4 % men; median age: 56.5 years). The ORR was 15.4 % (95 % confidence interval [CI] 6.9-28.1); 8 patients achieved partial responses for a median duration of 3.1 months (95 % CI 2.6-4.1 months) and 26 patients (50.0 %) had stable disease. Median progression-free survival was 2.8 months (95 % CI 2.1-3.5 months). The most common grade 3 non-hematological toxicities were fatigue (9.6 %), decreased appetite (7.7 %), sensory neuropathy (5.8 %), and diarrhea (5.8 %). Grade 3/4 neutropenia occurred in 46.2 % of patients.

CONCLUSIONS

Ixabepilone is active in Asian patients with advanced gastric cancer and shows a toxicity profile similar to those previously reported in other tumor types.

Surgical approaches to gastric cancer

While the incidence of gastric cancer has declined substantially, it remains a major cause of morbidity and mortality. Surgical resection offers the best chance for curative treatment. Despite numerous studies, surgical controversies persist including endoscopic resection, extent of gastric resection, degree of lymphadenectomy, and laparoscopic resection. Balancing the benefits with the risks of surgical morbidity and mortality is essential. This review examines these controversies and provides insight into the surgical management of gastric cancer.

Clinical trials in gastric cancer and the future

Following the first successful gastric resection for gastric cancer by Theodor Billroth in 1881 surgery has made tremendous progress leading to improved surgical mortality and morbidity. However, while treatment of early gastric cancer is frequently curative, 5-year survival rates for advanced gastric cancer remain dismal despite the application of perioperative multimodal treatment concepts. In this article we will outline key clinical trials that have lead to an improvement in treatment of gastric cancer patients with specific emphasis on the last 20 years. We will then outline recent concepts and key clinical trials that are currently being conducted in the field. Finally we will outline open questions that remain to be elucidated in the future.

Efficacy and safety of XELOX and FOLFOX6 adjuvant chemotherapy following radical total gastrectomy

The purpose of this study was to compare the efficacy and safety of capecitabine and oxaliplatin (XELOX) with 5-fluorouracil, folinic acid and oxaliplatin (FOLFOX6) for advanced gastric cancer following total gastrectomy. We performed a retrospective study of 148 gastric cancer patients undergoing total gastrectomy combined with adjuvant chemotherapy from January, 2003 to June, 2009. The follow-up lasted until December, 2010. The Chi-square test and Kaplan-Meier methods were employed to compare the adverse events and prognosis. The total 1-, 3- and 5-year survival rates were 95, 80 and 32%, respectively, and there was no significant difference between the two groups (P=0.273). Similarly, the total incidence of side effects was similar, but each treatment was associated with unique disturbances. The number of patients developing hand-foot syndrome in the XELOX group was far higher compared to the FOLFOX6 group (P=0.000). By contrast, more patients in the FOLFOX6 group suffered from nausea (P=0.024), vomiting (P=0.029), alopecia (P=0.033) and peripheral phlebitis (P=0.004). The total completion rate of the XELOX group was higher compared to the FOLFOX6 group (P=0.015). No significant difference was found in the prognosis of patients receiving XELOX therapy or FOLFOX6 therapy following total gastrectomy. XELOX was, however, more tolerable for patients with total gastrectomy.

Identification of novel molecular markers for detection of gastric cancer cells in the peripheral blood circulation using genome-wide microarray analysis

Although metastasis or relapse is a leading cause of death for patients with gastric cancer, the hematogenous spread of cancer cells remains undetected at the time of initial therapy. The development of novel diagnostic molecular marker(s) to detect circulating gastric cancer cells is an issue of great clinical importance. We obtained peripheral blood samples from 10 patients with gastric cancer who underwent laparotomy and 4 healthy volunteers. Microarray analysis consisting of 30,000 genes or ESTs was carried out using eight gastric cancer tissues and normal gastric mucosae. We selected 53 genes up-regulated in gastric cancer compared to normal gastric mucosae from our microarray data set, and, among these, identified five candidate marker genes (TSPAN8, EPCAM, MMP12, MMP7 and REG3A) which were not expressed in peripheral blood mononuclear cells (PBMCs) from 4 healthy volunteers. We further carried out semi-quantitative nested reverse transcription-polymerase chain reaction (RT-PCR) for HRH1, EGFR, CK20 and CEA in addition to the five newly identified genes using PBMCs of patients with gastric cancer, and found that expression of one or more genes out of the nine was detected in 80% of the patients with gastric cancer. Moreover, the numbers of genes expressed in PBMCs were ≤2 and ≥2 in all vascular invasion-negative cases and in 5 of 6 positive cases, respectively, showing significant differences between the two groups (P=0.041). Nested RT-PCR analysis for the set of nine marker genes using PBMCs may provide the potential for detection of circulating gastric cancer cells prior to metastasis formation in other organs.