Combined resection of invaded organs in patients with T4 gastric carcinoma

Prognostic value of GLIM-defined malnutrition in combination with hand-grip strength or gait speed for the prediction of postoperative outcomes in gastric cancer patients with cachexia

BACKGROUND

Cancer cachexia is associated with impaired functional and nutritional status and worse clinical outcomes. Global Leadership Initiative in Malnutrition (GLIM) consensus recommended the application of GLIM criteria to diagnose malnutrition in patients with cachexia. However, few previous study has applied the GLIM criteria in patients with cancer cachexia.

METHODS

From July 2014 to May 2019, patients who were diagnosed with cancer cachexia and underwent radical gastrectomy for gastric cancer were included in this study. Malnutrition was diagnosed using the GLIM criteria. Skeletal muscle index was measured using abdominal computed tomography (CT) images at the third lumbar vertebra (L3) level. Hand-grip strength and 6-meters gait speed were measured before surgery.

RESULTS

A total of 356 patients with cancer cachexia were included in the present study, in which 269 (75.56%) were identified as having malnutrition based on the GLIM criteria. GLIM-defined malnutrition alone did not show significant association with short-term postoperative outcomes, including complications, costs or length of postoperative hospital stays. The combination of low hand-grip strength or low gait speed with GLIM-defined malnutrition led to a significant predictive value for these outcomes. Moreover, low hand-grip strength plus GLIM-defined malnutrition was independently associated with postoperative complications (OR 1.912, 95% CI 1.151-3.178, P = 0.012). GLIM-defined malnutrition was an independent predictive factor for worse OS (HR 2.310, 95% CI 1.421-3.754, P = 0.001) and DFS (HR 1.815, 95% CI 1.186-2.779, P = 0.006) after surgery. The addition of low hand-grip strength or low gait speed to GLIM-defined malnutrition did not increase its predictive value for survival.

CONCLUSION

GLIM-defined malnutrition predicted worse long-term survival in gastric cancer patients with cachexia. Gait speed and hand-grip strength added prognostic value to GLIM-defined malnutrition for the prediction of short-term postoperative outcomes, which could be incorporated into preoperative assessment protocols in patients with cancer cachexia.

Prognostic factors in T4b gastric cancer after surgery: A more balanced and sequential therapy for patients?

INTRODUCTION

This study aimed to evaluate the prognostic factors in T4b gastric cancer (GC) in order to improve future therapeutic strategies.

METHODS

We retrospectively analyzed the medical records of 43 patients with advanced GC who underwent surgery and were surgically or pathologically diagnosed with T4b GC. The overall survival (OS) rate of patients with T4b GC was analyzed, and univariate and multivariate analyses were performed to identify clinicopathological factors that were independently associated with OS. In addition, we assessed the relationship between postoperative chemotherapy and laboratory parameters 4 weeks post-surgery.

RESULTS

The proportion of patients with invasion of cancer in organs, including the pancreas, transverse colon, and liver, were 58.1%, 18.6%, and 14.0%, respectively. The proportion of patients who exhibited distant metastases was 44.2%, and R0 resection was achieved in 30.2% of patients. A total of 69.8% of patients underwent postoperative chemotherapy. The median survival rate was 12.3 months. Upon multivariate analysis, the presence of distant metastases (P = 0.01, HR; 3.48), the use of postoperative chemotherapy (P = 0.0004, HR; 0.12), and R0 resection (P < 0.0001, HR; 0.14) were significantly correlated with OS. Patients who did not undergo postoperative chemotherapy showed significantly higher levels of inflammatory parameters and lower levels of nutritional parameters 4 weeks after surgery than those who did.

CONCLUSIONS

We evaluated that the presence of distant metastases was significantly associated with a poor prognosis, and the use of postoperative chemotherapy and R0 resection was significantly associated with a better prognosis in patients with T4b GC. It would be more important for a T4b GC treatment to balance between therapeutic tolerance for postoperative chemotherapy and surgical therapeutic effect.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Prognostic Impact of Number of Organ Invasions in Patients with Surgically Resected Thymoma

PURPOSE

This study aimed to explore the clinical implications and prognostic value of the number of organ/structure invasions (NOI) in patients with thymoma after curative surgical resection.

METHODS

We retrospectively analyzed 306 consecutive Japanese patients with thymoma who underwent curative surgical resection. Tumor invasions of pericardium, mediastinal pleura, phrenic nerve, lung, and venous structures were examined histopathologically. Cases were classified into four subgroups according to NOI: group 0, no tumor invasion; group 1, tumor invasion into single organ/structure; group 2, tumor invasion of two organs/structures; group 3, invasion of three or more organs/structures. Associations with NOI and several clinical characteristics and their prognostic significance were analyzed.

RESULTS

Pleural invasion was found in 100 cases (32.7%), lung invasion in 48 cases (15.7%), pericardial invasion in 46 cases (15%), phrenic nerve invasion in 29 (9.5%), and venous invasion in 22 cases (7.2%). NOI was classed as group 0 in 201 cases (65.0%), group 1 in 42 cases (13.7%), group 2 in 20 cases (6.5%), and group 3 in 43 cases (14.1%). Cases with higher NOI showed significantly worse relapse-free survival (RFS) and overall survival (OS). Cox's proportional hazard model analysis also identified NOI as a prognostic factor affecting RFS and OS.

CONCLUSIONS

Cases with higher NOI of thymoma after radical surgical resection showed significantly worse recurrence rates and survival.

Advanced gastric cancer with abdominal wall invasion treated with curative resection after chemotherapy: a case report

INTRODUCTION

In patients with gastric cancer, 6-27% of patients are diagnosed with T4b disease that invades adjacent organs, and curative resection can improve the prognosis of these patients.

CASE PRESENTATION

A 70-year-old Japanese man presented with an abdominal tumor and was diagnosed with advanced gastric cancer (L-Circ type 3 T4b N2 M0 H0 stage IVA, based on the 15th edition of the Japanese Classification of Gastric Carcinoma) with extensive abdominal wall invasion. We performed open gastrojejunal bypass for gastric obstruction and initiated a chemotherapeutic regimen comprising S-1 (120 mg/day) and oxaliplatin (100 mg/m2). Upper gastrointestinal endoscopy performed after the administration of six courses of the S-1 and oxaliplatin regimen revealed a persistent primary lower gastric wall lesion; however, the diameter of the abdominal wall invasion and metastatic lymph nodes was significantly reduced, in addition to decreased serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels. Subsequently, the patient underwent distal gastrectomy with D2 lymphadenectomy combined with transverse colon and abdominal wall resection. We performed radical en bloc resection and achieved a tumor-free resection margin. Simple abdominal wall closure was performed without mesh or musculocutaneous flap placement. Histopathological examination of the resected tumor specimen showed direct invasion of the mesocolon and rectus abdominis muscle. The patient was postoperatively diagnosed with L Gre-Ant type5 T4b (SI: rectus abdominis muscle) N2 PM0 DM0 Stage IIIA R0 Grade 2a gastric cancer based on histopathological findings and received S-1 as adjuvant chemotherapy, 2 months postoperatively. No recurrence was detected 6 months postoperatively.

CONCLUSIONS

We report a case of advanced gastric cancer with extensive abdominal wall invasion that was successfully treated with gastrectomy combined with resection of adjacent organs showing tumor invasion after effective systemic chemotherapy. A therapeutic approach comprising curative surgery combined with perioperative chemotherapy is useful in patients with T4b gastric cancer.

Multivisceral resection vs standard gastrectomy for gastric adenocarcinoma

INTRODUCTION

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

OBJECTIVES

Compare complications and survival after MVR and SG.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Liver resection as a component of en-bloc multivisceral resection for upper abdominal tumors is associated with increased morbidity

BACKGROUND AND METHODS

Complex en-bloc multivisceral and oncovascular resections for upper abdominal tumors remain rare, but there is increasing interest in their role. We analyze complications and survival for these operations. We performed a retrospective cohort study of patients who underwent en-bloc upper abdominal resections for tumors involving multiple organs. Primary outcomes were complications as per the Clavien-Dindo Classification and Comprehensive Complication Index (CCI). Secondary outcome was overall survival (OS).

RESULTS

We identified 60 consecutive patients who underwent resection from 2011 to 2018. Histopathology was heterogeneous, the most common being renal cell carcinoma. Eighteen patients had major complications. Mean (interquartile range) CCI was 29.6 (9.6-43.9). Liver resection was significantly associated with an increased CCI and increased the odds of a major complication (odds ratio: 4.67, 95% confidence interval [CI]: 1.31-16.59; P = .017). Charlson Comorbidity Score was significantly associated with the presence of at least one major complication. Mean OS was 47.1 months (95% CI: 37.6-56.6).

CONCLUSION

In appropriately selected patients, and when undertaken in centers with appropriate subspecialist surgical teams and intensive care services, en-bloc multivisceral resection of upper abdominal tumors is safe, but liver resection is associated with an increase in major complications.

Nationwide Outcome of Gastrectomy with En-Bloc Partial Pancreatectomy for Gastric Cancer

BACKGROUND

Radical gastrectomy is the cornerstone of the treatment of gastric cancer. For tumors invading the pancreas, en-bloc partial pancreatectomy may be needed for a radical resection. The aim of this study was to evaluate the outcome of gastrectomies with partial pancreatectomy for gastric cancer.

METHODS

Patients who underwent gastrectomy with or without partial pancreatectomy for gastric or gastro-oesophageal junction cancer between 2011 and 2015 were selected from the Dutch Upper GI Cancer Audit (DUCA). Outcomes were resection margin (pR0) and Clavien-Dindo grade ≥ III postoperative complications and survival. The association between partial pancreatectomy and postoperative complications was analyzed with multivariable logistic regression. Overall survival of patients with partial pancreatectomy was estimated using the Kaplan-Meier method.

RESULTS

Of 1966 patients that underwent gastrectomy, 55 patients (2.8%) underwent en-bloc partial pancreatectomy. A pR0 resection was achieved in 45 of 55 patients (82% versus 85% in the group without additional resection, P = 0.82). Clavien-Dindo grade ≥ III complications occurred in 21 of 55 patients (38% versus 17%, P < 0.001). Median overall survival [95% confidence interval] was 15 [6.8-23.2] months. For patients with and without perioperative systemic therapy, median survival was 20 [12.3-27.7] and 10 [5.7-14.3] months, and for patients with pR0 and pR1 resection, it was 20 [11.8-28.3] and 5 [2.4-7.6] months, respectively.

CONCLUSIONS

Gastrectomy with partial pancreatectomy is not only associated with a pR0 resection rate of 82% but also with increased postoperative morbidity. It should only be performed if a pR0 resection is feasible.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

[Multivisceral resection with and without HIPEC in cancer surgery]

BACKGROUND

Multivisceral resections seem to be naturally associated with an elevated morbidity rate. Data regarding the impact of multivisceral resections on progression-free and overall survival are only available in insufficient quantities.

OBJECTIVE

Data on multivisceral resections in cancer surgery are presented exemplified by gastric cancer, colorectal cancer and peritoneal metastases, focusing on overall and progression-free survival as well as morbidity and mortality.

MATERIAL AND METHODS

A PubMed search was carried out including the following terms: multivisceral resection, peritoneal metastases, cytoreduction, morbidity, HIPEC (hyperthermic intraperitoneal chemotherapy) RESULTS: Multivisceral resections should only be performed if an R0 status can be achieved for all tumor entities. Preoperative performance of an FDG-PET-CT scan (fluorodeoxyglucose positron emission tomography computed tomography scan) can help in the selection of appropriate patients. In gastric cancer, extensive lymphatic metastases are associated with a poor overall survival despite multivisceral resection. Recurrent rectal cancer shows elevated morbidity rates and also decreased overall survival rates. Maximum cytoreductive surgery can be conducted for peritoneal metastasized appendiceal neoplasms and colorectal cancer with acceptable morbidity and without an increased risk for reduced overall survival.

CONCLUSION

After adequate patient selection and exclusion of stage IV distant metastatic disease, multivisceral resections can be offered to patients with the goal of an R0 resection.

The role of the CCL22-CCR4 axis in the metastasis of gastric cancer cells into omental milky spots

Background

The omentum is one of the initial sites for peritoneal metastasis because it possesses milky spots that provide a microenvironment for cancer cells to readily migrate and grow into micrometastases. This study investigated the role of the CCL22-CCR4 axis in gastric cancer cells selectively infiltrating into milky spots.

Methods

Gastric cancer MFC cells labelled with DiI were injected intraperitoneally into strain 615 mice. The mice were euthanised at specified intervals and the omentum was excised for immunohistochemistry. The effects of CCL22 on the proliferation and migration of MFCs were assessed by MTT and trans-well assays. RT-PCR and Western blot analysis detected CCR4 mRNA and protein expression levels in MFCs. Immunohistochemistry was used to analyse CCL22 and CCR4 expression in the milky spot micrometastases.

Results

Two weeks after intraperitoneal injection, the milky spot areas were completely occupied by proliferating gastric cancer cells and cell cluster-type micrometastases were observed. In contrast, cancer cells formed single cell-type micrometastases in the non-milky spot areas. MFCs expressed CCR4, which was localised on the cell surface and or in the cytoplasm. Different concentrations of CCL22 significantly increased the proliferation ability of MFCs. Additionally, concentrations of CCL22 between 10–100 ng/ml significantly increased the migration of MFCs. Within omental milky spots, CCL22 was localised mainly on the cell surface and or in the cytoplasm. Within sections of omental milky spot micrometastases, CCR4 was recognised on or in gastric cancer cells, constituent cells milky spots, blood cells and blood endothelial cells.

Conclusions

Omental milky spots are a congenial microenvironment for peritoneal free gastric cancer cells to migrate, survive, and establish cell cluster-type metastases. The CCL22-CCR4 axis contributes to this selective infiltration process.

Diagnostic values of carcinoembryonic antigen in predicting peritoneal recurrence after curative resection of gastric cancer: a meta-analysis

AIM

A meta-analysis was performed to assess the diagnostic values of carcinoembryonic antigen (CEA) in predicting the peritoneal recurrence after curative resection of gastric cancer.

METHODS

The Medline, Embase, Web of Science, Ovid and Cochrane databases, Google Scholar and Vivisimo engines were searched to identify studies reporting on the accuracy of CEA protein or CEA mRNA in predicting the postoperative peritoneal recurrence of gastric cancer. Publication bias was demonstrated by Funnel plots and Egger test. The sensitivity, specificity, and diagnostic odds ratio (DOR) were calculated and summary receiver operating characteristic curves were generated.

RESULTS

Seven and eight studies fulfilled the inclusion criteria for CEA protein and mRNA determination, including 635 and 849 patients, respectively. The pooled sensitivity, specificity and DOR of CEA protein for predicting the peritoneal recurrence were 0.77 (95 % CI 0.69-0.84), 0.89 (95 % CI 0.86-0.92), 29.71 (95 % CI 10.27-85.92), respectively. Similarly, the values for CEA mRNA were 0.82 (95 % CI 0.75-0.88), 0.82 (95 % CI 0.79-0.85) and 22.97 (95 % CI 10.90-48.41). Meanwhile, the sensitivity and DOR of CEA protein or mRNA were higher than those of cytology, while higher specificity was noted in cytology assay.

CONCLUSION

CEA protein and mRNA levels in peritoneal lavage show a high diagnostic accuracy and may help accurately predict the peritoneal recurrence after curative resection of gastric cancer.

Multivisceral resection for gastric cancer: a systematic review

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Systematic review of pancreaticoduodenectomy for locally advanced gastric cancer

BACKGROUND

The purpose of this study was to identify and synthesize findings from all articles on surgical and long-term outcomes in patients with gastric cancer undergoing gastrectomy combined with pancreaticoduodenectomy (PD).

METHODS

Electronic literature searches were conducted using Medline, EMBASE, and Cochrane databases from January 1, 1985, to December 31, 2009.

RESULTS

Eight retrospective case series were included, with 132 patients having PD combined with gastrectomy. PD was combined with total gastrectomy in 27 patients, and subtotal gastrectomy in 81 patients; 24 patients had undocumented gastric resection type. Clinical stage was available for 92 patients (4 stage I, 7 stage II, 26 stage III, and 55 stage IV). Five studies (98 patients having PD combined with gastrectomy) compared PD and gastrectomy to gastrectomy alone. In the four studies reporting morbidity, PD had a higher morbidity. The pooled pancreatic anastomotic leak rate was 24.5% for the seven studies in which complications were reported; however, there were no peri-operative deaths. Long-term survival (37.3% at 5 years) in gastric cancer patients with PD combined with gastrectomy was described; however, survival was poor in the setting of incurable factors. Due to heterogeneity of patients and staging techniques in the case series no recommendations can be made on the appropriate selection criteria for patients undergoing PD and gastrectomy.

CONCLUSION

PD for gastric cancer invading the pancreas is associated with a higher morbidity; given the heterogeneous data, defining exact selection criteria is difficult.

Systematic review of the predictors of positive margins in gastric cancer surgery and the effect on survival

BACKGROUND

Complete resection is the only definitive treatment available for gastric cancer. Factors associated with positive margins and their survival effects have been the subject of many studies, but the appropriate management for these patients is still debated. The objective of this review is to examine positive margins after gastric cancer resections by exploring predictive factors, impact on survival, and optimal strategies for re-resection.

METHODS

A systematic electronic literature search was conducted using Medline and EMBASE from January 1, 1998, to December 31, 2009. Studies on gastric or gastroesophageal junction adenocarcinoma that either investigated the predictors for positive margin or employed multivariate methods to analyze the survival effects of positive margins were selected.

RESULTS

Twenty-two studies incorporating 19355 patients were included in this review. Positive margins were associated with larger tumor size, deeper wall penetration, more extensive gastric involvement, greater nodal involvement, higher stage, diffuse histology, higher Borrmann type, lymphatic vessel involvement, and total gastrectomy. Patient survival was independently associated with margin status, and this survival effect was more prominent in early cancers in most studies that performed subgroup analyses.

CONCLUSIONS

The probability of acquiring positive margins is highly dependent on the biology and the extent of the tumor. There is a significant negative effect on survival, which is more prominent in cancers at early stages, making re-resection or a second operation important. Patients with more advanced disease can be offered more extensive surgery to remove disease, but this should be balanced against the risks of more extensive resections.

Prognostic factors of T4 gastric cancer patients undergoing potentially curative resection

AIM: To investigate the prognostic factors of T4 gastric cancer patients without distant metastasis who could undergo potentially curative resection.

METHODS: We retrospectively analyzed the clinical data of 71 consecutive patients diagnosed with T4 gastric cancer and who underwent curative gastrectomy at our institutions. The clinicopathological factors that could be associated with overall survival were evaluated. The cumulative survival was determined by the Kaplan-Meier method, and univariate comparisons between the groups were performed using the log-rank test. Multivariate analysis was performed using the Cox proportional hazard model and a step-wise procedure.

RESULTS: The study patients comprised 53 men (74.6%) and 18 women (25.4%) aged 39-89 years (mean, 68.9 years). Nineteen patients (26.8%) had postoperative morbidity: pancreatic fistula developed in 6 patients (8.5%) and was the most frequent complication, followed by anastomosis stricture in 5 patients (7.0%). During the follow-up period, 28 patients (39.4%) died because of gastric cancer recurrence, and 3 (4.2%) died because of another disease or accident. For all patients, the estimated overall survival was 34.1% at 5 years. Univariate analyses identified the following statistically significant prognostic factors in T4 gastric cancer patients who underwent potentially curative resection: peritoneal washing cytology (P < 0.01), number of metastatic lymph nodes (P < 0.05), and venous invasion (P < 0.05). In multivariate analyses, only peritoneal washing cytology was identified as an independent prognostic factor (HR = 3.62, 95% CI = 1.37-9.57) for long-term survival.

CONCLUSION: Positive peritoneal washing cytology was the only independent poor prognostic factor for T4 gastric cancer patients who could be treated with potentially curative resection.

Transverse mesocolon invasion in advanced gastric cancer: should we reconsider current T staging?

BACKGROUND

According to the AJCC/UICC TNM classification, T mesocolon invasion in AGC is classified as T2b or T3 according to the presence or the absence of serosa invasion. However, many authors have considered T mesocolon invasion in AGC as T4. This study was performed to evaluate the appropriate T stage for T mesocolon invasion in AGC.

MATERIALS AND METHODS

From 1996 to 2008, 90 patients underwent curative gastrectomy with T mesocolon excision at the authors' institute under the suspicion of T mesocolon invasion based on surgical findings and without pathologic invasion to any other organ. Histopathologic findings were reviewed to determine whether tumors had invaded the T mesocolon. Survival data of AGC patients registered in the SNUH database (N = 9998, from 1986 to 2007) was used as reference data for comparative purposes.

RESULTS

A total of 27 patients (30%) had proven histopathological invasion of the T mesocolon, and a significant difference in survival rates was found between these 27 and the remaining 63 (P = .012). As compared with the SNUH database population, the survival rate of T mesocolon invasion patients differed from those of T2b (P < .001) and T3 (P = .043) patients, but was similar to that of T4 patients (P = .218). Furthermore, for N1 stage patients, the survival rate differed from those of T2b (P = .001) and T3 (P = .046) patients, but was similar to that of T4 patients (P = .744).

CONCLUSIONS

The T stage of T mesocolon invasion in AGC should be revised to AJCC/UICC stage T4, because the survival rate of T mesocolon invasion AGC is lower than that of stage T2b or T3.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prognosis and surgical treatment of gastric cancer invading adjacent organs

BACKGROUND

The prognostic factors and surgical management of gastric cancer invading adjacent organs remains controversial. The aim was to provide valuable prognostic and surgical information on patients with gastric cancer invading adjacent organs.

METHODS

The retrospectively study included 367 patients who underwent gastric resection for gastric cancer invading adjacent organs. Clinicopathologic variables were evaluated as predictors of long-term survival by univariate and multivariate analyses. Multivariate analysis was performed using Cox's proportional hazards model.

RESULTS

The five-year survival rate was 10.1%, and median survival period was 14 months. The five-year survival rate was influenced by histologic type, lymph node metastasis, liver metastasis, peritoneal dissemination, extent of lymph node dissection and curability of operation. Of these, independent prognostic factors were lymph node metastasis (N2, N3 versus N0, N1, relative risk 2.028, P < 0.001), liver metastasis (present versus absent, relative risk 1.582, P= 0.023) and curative resection (no versus yes, relative risk 1.719, P < 0.001). A significant survival benefit for curative resection was observed with a five-year survival rate of 21.5% compared with non-curatively resected cases (5.1%).

CONCLUSIONS

In patients with gastric cancer invading adjacent organs, three independent prognostic factors were lymph node metastasis, liver metastasis, and curative resection. For patients with gastric cancer invading adjacent organs, we recommend performing combined organ resection in patients with locally advanced gastric carcinoma regardless of curability.

Subclassification of stage IV gastric cancer (IVa, IVb, and IVc) and prognostic significance of substages

BACKGROUND

Although the prognosis of stage IV gastric cancer is poor, some patients with stage IV gastric cancer had a long-term survival after gastrectomy. The objective of this study was to subclassify stage IV gastric cancer according to survival differences, evaluate the prognosis by substage, and identify the factors associated with patient survival in each substage.

METHODS

The data from 1,176 patients who underwent gastric resection for stage IV gastric cancer between 1988 and 2007 at Tumor Hospital of Harbin Medical University were reviewed retrospectively. The patients were divided into three substages according to the survival differences: stage IVa (T1-2N3M0), stage IVb (T3N3M0 and T4N1-2M0), and stage IVc (T4N3M0 and TanyNanyM1). The clinicopathological characteristics as well as survival of the patients were evaluated retrospectively by substage.

RESULTS

There were no significant differences in survival among T3N3M0, T4N1M0, and T4N2M0 groups (p = 0.884) and between T4N3M0 and TanyNanyM1 groups (p = 0.192). The 5-year survival rates in stage IVa (T1-2N3M0), stage IVb (T3N3M0 and T4N1-2M0), and stage IVc (T4N3M0 and TanyNanyM1) were 22.7%, 9.9%, and 2.2%, respectively (p < 0.001). Multivariate analysis showed the following independent prognostic factors for survival: subclassification, operation type, number of retrieved lymph nodes, curability, and chemotherapy for stage IV gastric cancer; curability, chemotherapy, and number of retrieved lymph nodes for stage IVa and IVb; chemotherapy and operation type for stage IVc. For 406 patients with curative resection in stage IVa and IVb, hematogenous recurrence (35.9%) was the dominant recurrence pattern in stage IVa, whereas the most common patterns of recurrence were peritoneal (40.8%) and locoregional recurrence (31.8%) in stage IVb.

CONCLUSIONS

Subclassification of stage IV gastric cancer into IVa (T1-2N3M0), IVb (T3N3M0 and T4N1-2M0), and IVc (T4N3M0, TanyNanyM1) may be helpful to predict the outcome and determine the therapeutic strategies for patients with stage IV gastric cancer.

Should direct mesocolon invasion be included in T4 for the staging of gastric cancer?

BACKGROUND AND OBJECTIVES

One of the sites most frequently invaded by gastric cancer is the mesocolon; however, the UICC does not mention this anatomical site as an adjacent structure involved in gastric cancer. The purpose of this study was to characterize and classify mesocolon invasion from gastric cancer.

METHODS

We examined 806 patients who underwent surgery for advanced gastric carcinoma from 1992 to 2007 at the Department of Surgery, Gangnam Severance Hospital, Korea. Among these, patients who showed macroscopically direct invasion into the mesocolon were compared to other patients with advanced gastric cancer.

RESULTS

The curability, number and extent of nodal metastasis, and the survival of the mesocolon invasion group were significantly worse than these factors in the T3 group. However, the survival of the mesocolon invasion group after curative resection was much better than that of patients who had incurable factors.

CONCLUSIONS

Mesocolon invasion should be included in T4 for the staging of gastric cancer.

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

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pancreaticoduodenectomy for locally advanced stomach cancer: preliminary results

BACKGROUND

Pancreaticoduodenectomy (PD) for locally advanced stomach cancer involving duodenum or/and pancreatic head was controversial and rarely carried out. It was mainly reported from the Japanese institutions.

METHODS

A review of prospective database from January 2003 to December 2006 of patients who had locally advanced stomach cancer involving duodenum or/and head of pancreas that precluded curative subtotal gastrectomy who underwent diagnostic laparoscopy or exploratory laparotomy to exclude peritoneal metastatic disease. Patients were advised to undergo neoadjuvant chemotherapy before PD.

RESULTS

Seven patients underwent PD during the above-mentioned period. Only four patients had neoadjuvant chemotherapy before PD. The median operative time was 8 h (range 6-9 h). Five patients had combined tranverse colectomy done. There was no 30-day operative mortality or re-operation. Three patients developed controlled pancreatic leaks and fistulas that were successfully treated with conservative measures. The length of hospital stay was 10-53 days (median 15 days). Median survival was 13 months and 2-year survival rate was 60%. Patients who received neoadjuvant chemotherapy seemed to have better survival rate (P = 0.039).

CONCLUSION

Our initial experience has shown that with careful and stringent patients selection, PD for locally advanced stomach cancer can be carried out with acceptable morbidity and mortality. Early results for patients who received neoadjuvant chemotherapy showed trend towards prolonged survival. However, longer follow up and further patient recruitment are needed to confirm our initial optimistic findings.

Prognosis of gastric carcinoma invading the mesocolon

OBJECTIVE

The prognosis is poor when gastric carcinoma invades adjacent organs. We evaluated the outcome indicators in gastric carcinoma patients with mesocolon invasion.

METHODS

We reviewed the hospital records of 169 gastric carcinoma patients with mesocolon invasion seen between 1986 and 2000 at Chonnam National University Hospital.

RESULTS

The curative resection rate in gastric carcinoma patients with mesocolon invasion was 29.6% (50/169). Using Cox's proportional hazards regression model, curability was the only independent, statistically significant prognostic parameter (risk ratio, 1.48; 95% confidence interval, 0.902.46; p < 0.05). The 5-year survival rate was higher for patients who underwent curative resection (15.5%) than for those who underwent non-curative resection (2.6%; p < 0.001). The 5-year survival rate was higher for patients who underwent resection (7.3%) than for those who did not (bypass and exploration groups, 5.1% and 0%, respectively; p < 0.001).

CONCLUSION

The results showed improved survival of gastric carcinoma patients with mesocolon invasion who underwent curative resection compared to those who did not. Improving the prognosis for patients with mesocolon invasion requires curative resection.

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

BACKGROUND AND OBJECTIVE

Indications for gastrectomy in T4 gastric carcinoma (GC) remain controversial. Our aim was to define prognostic factors to select those patients with best chance to benefit from multiorgan resection.

MATERIALS AND METHODS

A cohort of patients with T4 GC treated in a 19-year period. Surgical morbidity-associated factors were identified by logistic regression analysis. Prognostic factors were defined by Kaplan-Meier and Cox methods.

RESULTS

Seven hundred eighteen patients were included (gastrectomy performed in 169). Surgical morbidity and mortality were 39% and 10.7%, respectively. Surgical morbidity were associated to extent of gastrectomy, age, serum albumin, and lymphocyte count (P = 0.0001). Presence of metastasis (hazard ratio [HR], 1.68; 95% confidence interval [95% CI], 1.19-2.36), albumin <3 g/dl plus lymphocytes <1,000 cells/mm(3) (HR, 2.9; 95% CI, 1.8-4.6), presence of ascites (HR, 2.1; 95% CI, 1.06-4.2), age >or=50 (HR, 1.37; 95% CI, 1.02-1.8), and unresectable disease (HR, 2.6; 95% CI, 1.7-4.1) defined poor survival (P = 0.00001).

CONCLUSION

Performing a multiorgan resection must be balanced between chances for long-term survival and surviving a potentially fatal operation. Absence of metastases, serum albumin levels >3 g/dl, and accomplishment of R0 resection select patients with high probability of benefit from multiorgan resection.

Advanced gastric cancer with a duplicated hepatic artery: preoperative diagnostic value of multidetector-row computed tomography for surgical resection

A 63-year-old woman with appetite loss and general fatigue underwent gastrointestinal fiberscopy, which revealed type 2 advanced gastric cancer. Multidetector-row computed tomography revealed a massive gastric cancer invading the left hepatic lobe, pancreatic head, and common hepatic artery, as well as revealing a duplicated hepatic artery in which the right hepatic artery branched directly from the celiac axis, and ran behind the splenic vein. On the other hand, the common hepatic artery ran anterior to the splenic vein. We were able to perform pancreaticoduodenectomy with common hepatic artery resection and left lobectomy as curative surgery because her duplicated hepatic artery enabled us to ligate the common hepatic artery. Her postoperative clinical course was uneventful, and she is in good health 3 years after the surgery, without recurrence. We consider that multidetector-row computed tomography is very useful for the diagnosis of vascular anomaly, preoperative staging and decision making on the appropriate surgical strategy.

T4 gastric carcinoma: the benefit of non-curative resection

BACKGROUND

The prognosis of patients with gastric carcinoma with invasion of the adjacent organs (T4 gastric carcinoma) is very poor. We evaluated the survival benefit of resection in this group of patients.

METHOD

We retrospectively reviewed the hospital records of 288 patients with T4 gastric carcinoma to compare the clinicopathological results in patients with curative resection (n = 95) with patients with non-curative resection (n = 193) during the period 1986-2000.

RESULTS

With a 33% curative resectability in patients with T4 gastric carcinoma, patients with tumour resection (curative and non-curative) had a significantly improved survival rate. The overall survival rate was higher for patients who underwent resection (11.6%) than for patients who were not resected (2.5%), regardless of curability (P < 0.001). Using Cox's proportional hazard regression model, lymph node invasion and curability were independent statistically significant prognostic parameters. The prognosis of patients with invasion to the peritoneum and adrenal glands was significantly poorer than that of patients in whom there was no such invasion. But, the number of organs invaded had no effect on patient survival.

CONCLUSIONS

Patients with T4 gastric carcinoma might be benefited from curative resection. The results also emphasize the improved survivorship of T4 gastric carcinoma patients with resection compared with those who did not undergo resection. Although curative resection cannot be undertaken in patients with T4 gastric carcinoma, we recommend performing resection in patients with locally advanced gastric carcinoma, regardless of curability.

Surgical outcomes in patients with T4 gastric carcinoma

BACKGROUND

There is controversy about the best therapeutic surgical approach for treatment of patients with T4 gastric cancer.

STUDY DESIGN

We used univariate and multivariate analyses to review the surgical outcomes and prognostic factors of 117 patients who underwent surgery for T4 gastric carcinoma.

RESULTS

Curative resection was performed in 38 (32.4%) patients, with the pancreas being the most frequently resected organ. The 5-year survival rate was 16.0% and the median survival time (MST) was 11 months for all 117 registered patients. The 5-year survival rates and MSTs in patients after curative and noncurative resection were 32.2% versus 9.5% and 20 months versus 8 months, respectively. These values differed considerably between the two groups (p < 0.0001). Curability was an independent prognostic factor among all registered patients, including those who underwent noncurative resection. A relatively small tumor diameter (< 100 mm) and few lymph node metastases (six or fewer metastatic lymph nodes) were independent prognostic factors when curative resection could be performed. Postoperative morbidity and mortality were acceptable after curative combined resection.

CONCLUSIONS

We recommend the use of aggressive combined resection of adjacent organs, with extended lymph node dissection, for patients with T4 gastric carcinoma in whom curative resection can be used; that is, those with few metastatic lymph nodes (six or less) and a relatively small tumor diameter (100 mm). But noncurative resection should be avoided in patients with T4 gastric cancer.

Extended multiorgan resection for T4 gastric carcinoma: 25-year experience

BACKGROUND AND OBJECTIVES

In locally advanced gastric carcinoma infiltrating adjacent organs, an extended resection including invaded organs is required to improve the prognosis. We retrospectively analyzed our experience with extended multiorgan resection (EMR) in patients with advanced gastric cancer.

METHODS

Between December 1979 and April 2004, 65 patients were resected for extended gastric carcinoma macroscopically invading other organs. Various clinicopathologic factors influencing early and late results were evaluated. Survival rates were calculated according to the Kaplan-Meier method. Prognostic factors were evaluated by univariate and multivariate analysis.

RESULTS

The majority of patients (61.5%) did receive a R0 curative resection. In 52 (80%) of the 65 presumed T4 cancers, histologic final analysis confirmed invasion. Postoperative morbidity and mortality was 27.7% and 12.3%, respectively. Actuarial 5-year overall survival (OS) rate was 21.8%. It was significantly better in R0 versus R+ (30.6% vs. 0%, P = 0.001). Multivariate analysis identified curative resection as the strongest predictor of survival (P = 0.002).

CONCLUSIONS

Patients with locally advanced gastric carcinoma invading adjacent organs can benefit from aggressive surgical treatment with acceptable morbidity and mortality. However, curative resection is mandatory to improve prognosis.

Aggressive surgical treatment for T4 gastric cancer

Surgical treatment for locally advanced gastric cancer remains controversial, and many still question the benefits of extended resection. The aim of this study was to evaluate the effectiveness of combined resection of the involved organs with regard to survival in patients with gastric cancer. Between 1993 and 2000, among the 1638 patients with gastric cancer who underwent gastrectomy, 82 were found to have evidence of adjacent organ spread at laparotomy. A retrospective analysis of these patients was performed. Curative resections were carried out in 50 patients, whereas noncurative resections were performed in 32 patients. The 5-year survival rate in the group undergoing curative resection was 36.9%. The survival rate in the R0 group was significantly higher than the survival rate for patients undergoing noncurative resections. There was no significant difference in survival rates between patients with pT3 cancer and those with pT4 cancer. Seventy-one patients were pathologically proved to have lymph node metastasis, and the survival rate for patients with a lymph node ratio greater than 0.2 was lower than that in other groups. In multivariate analysis, peritoneal dissemination, lymph node ratio, and histologic findings were the predictors of survival. Patients with T4 gastric carcinoma, even with lymph node metastasis, might have benefited from aggressive surgery with curative intent.

Gastric cancer cell detection in peritoneal washing: cytology versus RT-PCR for CEA transcripts

This study investigates the sensitivity and specificity of cytology, qualitative, and real-time RT-PCR methods in free cancer cell detection of peritoneal washing from gastric cancer patients. Peritoneal washings were collected from 65 gastric cancer patients for routine cytology and total RNA extraction for qualitative and real-time RT-PCR for CEA. The sensitivity and false-positive rate was 51.1%, 0% for cytology, 48.9% and 5% for qualitative RT-PCR for CEA, and 42.5% and 5% for real-time RT-PCR for CEA. The qualitative and real time RT-PCR results show high concordance rate (89.7%). The highest sensitivity was obtained by the combination of cytology with qualitative RT-PCR for CEA (70.2%). RT-PCR results were positive in 63.6% of cytologic "atypia" cases. Combination of cytology and either of the RT-PCR methods resulted in significantly higher sensitivity than any one of the three methods alone (P < 0.05). There was no definite advantage of the real-time RT-PCR over the conventional RT-PCR.