Laparoscopy, computerised tomography and fluorodeoxyglucose positron emission tomography in the management of gastric and gastro-oesophageal junction cancers

A preoperative predictive tool to assess the need for staging laparoscopy in oesophagogastric cancer patients

INTRODUCTION

Staging laparoscopy (SL) has become commonplace in the preoperative staging pathway for oesophagogastric (OG) cancer. SL is often performed before curative treatment to examine for macroscopic peritoneal metastases (PM) or positive peritoneal cytology (PPC). The aim of this study was to develop an objective risk scoring system to predict both PM and PPC at SL.

METHODS

A prospectively collected and maintained database of all OG cancer patients treated between 2006 and 2020 was reviewed. Univariate and multivariate analyses were performed to identify risk factors for both PM and PPC at SL. A risk score was produced for both PM and PPC, and then validated internally.

RESULTS

Among 968 patients who underwent SL, 96 (9.9%) had PM and 81 (8.4%) had PPC at SL. Tumour site (p < 0.001), computed tomography (CT) T stage (p < 0.001) and N stage (p = 0.029) were significantly associated with PM at SL (p < 0.001). Tumour site (p < 0.001), biopsy histology (p = 0.041), CT T stage (p < 0.001) and N stage (p < 0.001) were significantly associated with PPC. The risk scoring model for PM included cancer site and CT T stage. This was successfully tested on the validation set (area under the receiver operating characteristic [AUROC] = 0.730). The risk scoring model for PPC included cancer site, CT T and N stage. This was successfully tested on the validation set (AUROC = 0.773).

CONCLUSIONS

The current risk scores are valid tools with which to predict the risk PM and PPC in patients undergoing SL for OG cancer and may help to avoid subjecting patients to unnecessary SL.

Recent Advances in the Diagnosis, Staging, Treatment, and Prognosis of Advanced Gastric Cancer: A Literature Review

Gastric cancer is one of the most common cause of cancer related deaths worldwide which results in malignant tumors in the digestive tract. The only radical treatment option available is surgical resection. Recently, the implementation of neoadjuvant chemotherapy resulted in 5-year survival rates of 95% for early gastric cancer. The main reason of treatment failure is that early diagnosis is minimal, with many patients presenting advanced stages. Hence, the greatest benefit of radical resection is missed. Consequently, the main therapeutic approach for advanced gastric cancer is combined surgery with neoadjuvant chemotherapy, targeted therapy, or immunotherapy. In this review, we will discuss the various treatment options for advanced gastric cancer. Clinical practice and clinical research is the most practical way of reaching new advents in terms of patients' characteristics, optimum drug choice, and better prognosis. With the recent advances in gastric cancer diagnosis, staging, treatment, and prognosis, we are evident that the improvement of survival in this patient population is just a matter of time.

Clinical TNM staging for esophageal, gastric, and colorectal cancers in the era of neoadjuvant therapy: A systematic review of the literature

AIM

Clinical staging is vital for selecting appropriate candidates and designing neoadjuvant treatment strategies for advanced tumors. The aim of this review was to evaluate diagnostic abilities of clinical TNM staging for gastrointestinal, gastrointestinal cancers.

METHODS

We conducted a systematic review of recent publications to evaluate the accuracy of diagnostic modalities on gastrointestinal cancers. A systematic literature search was performed in PubMed/MEDLINE using the keywords "TNM staging," "T4 staging," "distant metastases," "esophageal cancer," "gastric cancer," and "colorectal cancer," and the search terms used in Cochrane Reviews between January 2005 to July 2020. Articles focusing on preoperative diagnosis of: (a) depth of invasion; (b) lymph node metastases; and (c) distant metastases were selected.

RESULTS

After a full-text search, a final set of 55 studies (17 esophageal cancer studies, 26 gastric cancer studies, and 12 colorectal cancer studies) were used to evaluate the accuracy of clinical TNM staging. Positron emission tomography-computed tomography (PET-CT) and/or magnetic resonance imaging (MRI) were the best modalities to assess distant metastases. Fat and fiber mode of CT may be useful for T4 staging of esophageal cancer, CT was a partially reliable modality for lymph node staging in gastric cancer, and CT combined with MRI was the most reliable modality for liver metastases from colorectal cancer.

CONCLUSION

The most reliable diagnostic modality differed among gastrointestinal cancers depending on the type of cancer. Therefore, we propose diagnostic algorithms for clinical staging for each type of cancer.

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.

Role of staging laparoscopy for gastric cancer patients

Staging laparoscopy (SL) is frequently carried out in patients with advanced gastric cancer. However, some clinical questions are being debated and consensus must be obtained. With this aim, a literature search of PubMed/MEDLINE was carried out using the keywords "gastric cancer," "SL," and "diagnostic laparoscopy". Articles published online up to February 2019 were analyzed, focusing on the following questions. (i) What is an adequate indication for SL? (ii) How do you carry out SL? (iii) Does SL provide accurate information about peritoneal dissemination? (iv) Is the yield of SL different by tumor location? (v) Is SL a safe procedure? (vi) Is "repeat SL" needed? (vii) Does SL provide oncological benefit? Results provided the following responses: (i) In Western countries, clinically resectable advanced tumor is an indication for SL. Terms to be introduced for adequate indication include "location," "type 4 (linitis feature)," "large tumor," "equivocal computed tomography (CT] findings," and "lymph node swelling". (ii) Exploration of the entire peritoneal cavity is preferable. (iii) Detection rate of peritoneal disease is 43%-52% in Japanese institutions and 7.8%-40% in other countries. False-negative findings during SL were 0%-17%, and 10%-13% when limited to cytology. (iv) Yield of SL was higher in gastric cancer compared with esophagogastric junctional tumor. (v) SL-related complications were estimated to occur in 0.4%. (vi) Repeat SL is important after treatment. (vii) If the efficacy of neoadjuvant chemotherapy for patients with P0CY1 is established, SL can provide oncological benefit. SL can be carried out safely and effectively. Considering the prevalence of neoadjuvant treatment, the role of SL will become more important.

Should 18F-FDG PET/CT Be Routinely Performed in the Clinical Staging of Locally Advanced Gastric Adenocarcinoma?

PURPOSE

The aim of this study was to evaluate F-FDG PET/CT compared with conventional imaging techniques in the clinical management of patients with locally advanced gastric cancer (LAGC).

METHODS

A prospective study between January 2010 and December 2011 in patients with suspected LAGC was conducted in our hospital. F-FDG PET/CT, contrast-enhanced CT (CECT), endoscopic ultrasound, and laparoscopy were performed in all cases. Standard whole-body F-FDG PET/CT images were obtained centered on the stomach at 1 and 2 hours after injection of 4.0 MBq/kg of F-FDG. Findings were confirmed by histopathology or by imaging follow-up in nonoperable patients.

RESULTS

Fifty consecutive patients with confirmed LAGC (20 women, 30 men) with a mean ± SD age of 65.7 ± 12.1 years were included. Using Lauren classification, 24 patients were intestinal subtype, and 26 were diffuse subtype. Thirty-five patients with locoregional lymph node involvement and 22 with distant metastases were confirmed as peritoneal metastases (n = 15), retroperitoneal (n = 2) or mediastinal lymph nodes (n = 1), and liver (n = 3) or bone metastases (n = 1). Patients with signet ring carcinoma showed significantly less F-FDG uptake (P = 0.001). SUVmax correlated with tumor grading (P < 0.05). Standard and delayed F-FDG PET/CT and CECT images identified LAGC in 24, 27, and 28 of 30 patients, respectively. The sensitivity and specificity for F-FDG PET/CT and CECT to detect metastases were 68% and 100% and 64% and 93%, respectively. Contrast-enhanced CT and F-FDG PET/CT diagnosed only 6 of the 15 patients with confirmed peritoneal metastases. The impact in therapeutic management of F-FDG PET/CT and CECT was 24% and 22%, respectively. Kaplan-Meier survival curves for the LGAC showed a significant correlation between SUVmax and overall survival using an SUVmax threshold of less than 3.96 (P = 0.04).

CONCLUSIONS

F-FDG PET/CT should be recommended for staging of LAGC; however, F-FDG PET/CT and CECT cannot replace laparoscopy to rule out peritoneal metastases. Delayed F-FDG PET/CT images show an increase of F-FDG uptake in most cases, improving LAGC detection. The grade of F-FDG uptake represents a significant prognostic tool in this series.

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.

Yield of Staging Laparoscopy for Incurable Factors in Chinese Patients with Advanced Gastric Cancer

BACKGROUND

Although the role of staging laparoscopy (SL) in detecting radiologically occult M1 disease has been widely recognized, it is seldom used in China and its clinical value based on Chinese population has been rarely reported. The aim of this study is to identify the yield of SL for Chinese patients with advanced gastric cancer (AGC) and determine the proportions of patients in whom treatment plan is altered.

MATERIALS AND METHODS

The clinical data were retrospectively collected from 879 AGC patients who underwent SL without any definite signs of disseminated disease on imaging examination. The primary outcomes were the proportions of patients whose laparoscopy identified incurable factors (including M1 diseases and unresectable T4b diseases), and who had their treatment plan altered.

RESULTS

SL revealed incurable factors in 130 (14.8%) patients, including macroscopic peritoneal metastasis (n = 92), positive peritoneal cytology (n = 10), liver metastasis (n = 12), para-aortic lymph node metastasis (n = 1), and unresectable T4b tumor (n = 18). After SL, treatment plans were altered in 123 (14.0%) patients, among which 82 (63.1%) patients were not offered any further procedure and referred for chemotherapy. Among 749 M0 patients who immediately proceeded to radical gastrectomy after SL, new incurable factors were found at subsequent operations in 21 (2.8%) patients. Multivariate analysis showed that tumor size ≥8 cm, Borrmann type III and IV, and tumor invasion of T4a and T4b in preoperative imaging examination were the predictive factors for peritoneal metastasis.

CONCLUSIONS

SL detects additional incurable factors in Chinese AGC patients with potentially resectable disease and optimizes their treatments. A systematic and painstaking inspection of the whole abdominal cavity, including routine entry into the bursa omentalis, is necessary for improving the yield of SL.

The value of staging laparoscopy in gastric cancer

Treatment options for patients with gastric cancer (GC) are based on tumor staging and resectability. Although only surgery provides improved survival, resection is contraindicated and should be avoided in the presence of intra-abdominal disease stage M1 (liver, peritoneal, or non-local lymph node metastases). Thus, a detailed and precise evaluation is imperative for optimal treatment. Staging laparoscopy (SL) constitutes a major tool in the accurate diagnosis of several types of cancers, including GC. SL presents several critical advantages: it can diagnose intra-abdominal disease; serve as a complement to other imaging studies; allow for biopsies; facilitate intraoperative ultrasound evaluations; allow for sampling of peritoneal fluid for cytological examination; and serve as an option for the administration of intraperitoneal chemotherapy. Although considered and advocated as a very useful asset in the pre-treatment cancer-staging arsenal, the wider application of SL has been long debated. The purpose of our study was to evaluate the contribution of laparoscopy to GC staging.