Incidence of metachronous gastric cancer in the remnant stomach after synchronous multiple cancer surgery

The value of lymph nodes ratios in the prognosis of resectable remnant gastric cancer through the retrospective propensity score matching analysis

PURPOSE

Currently, the characteristics and prognosis of remnant gastric cancer (RGC) are not fully understood yet. The present study aimed to describe the details of clinicopathological features of resectable RGC and investigated the factors affecting survival after the curative operation.

METHODS

From Jan. 2006 to Dec. 2015, a total of 118 resectable RGC patients (the RGC group) and 236 age-, sex- and TNM stages-matched resectable gastric cancer (GC) patients (the control group) were recruited retrospectively. Clinicopathological characteristics and overall survival were compared between the two groups.

RESULTS

The overall survival rate was 46.61% for RGC patients compared to 55.08% for control groups (P < 0.01), and the mean overall survival time of RGC patients was 40.23 ± 32.27 months, compared to 55.06 ± 34.29 months in the control group (P = 0.023 after matching). The overall survival (OS) of RGC patients with stage IIb was much worse than IIa (P < 0.001) and similar to IIIa (P = 0.463) and IIIb (P = 0.014). Multivariate Cox proportional hazards model analysis revealed that TNM stage (HR: 3.899, P < 0.001) and lymph nodes ratio (LNR) (HR: 2.405, P = 0.028) were independent prognostic significance to OS.

CONCLUSIONS

The OS of RGC was much worse than GC with similar TNM stages, and LNR might consider a highly reliable indicator to evaluate the prognostic in RGC.

Appraisal of gastric stump carcinoma and current state of affairs

Gastric stump carcinoma, also known as remnant gastric carcinoma, is a malignancy arising in the remnant stomach following gastrectomy for a benign or malignant condition. Enterogastric reflux and preexisting risk factors in a patient with gastric cancer are the major contributors to the development of gastric stump carcinoma. The occurrence of gastric stump carcinoma is time-dependent and seen earlier in patients operated on for malignant rather than benign diseases. The tumor location is predominantly at the anastomotic site towards the stomach. However, it can occur anywhere in the remnant stomach. The pattern of lymph node involvement and the type of surgery required is distinctly different compared to primary gastric cancer. Gastric stump carcinoma is traditionally considered a malignancy with a dismal outcome. However, recent advances in diagnostic and therapeutic strategies have improved outcomes. Recent advances in molecular profiling of gastric stump carcinoma have identified distinct molecular subtypes, thereby providing novel therapeutic targets. Also, reports of gastric stump carcinoma following pancreatoduodenectomy and bariatric surgery highlight the need for more research to standardize the diagnosis, staging, and treatment of these tumors. The present review aims to provide an overview of gastric stump carcinoma highlighting the differences in clinicopathological profile and management compared to primary gastric carcinoma.

Double tract reconstruction versus double flap technique: short-term clinical outcomes after laparoscopic proximal gastrectomy for early gastric cancer

BACKGROUND

Laparoscopic proximal gastrectomy (LPG) is increasingly preferred for operative management of early gastric cancer, although there is no consensus on a standard reconstruction method after resection. Two popular methods used after LPG are double tract reconstruction (DTR) and double flap technique (DFT). This study assessed comprehensive clinical outcomes including quality of life (QoL) and body composition change 1 year after DFT and DTR.

METHODS

We retrospectively reviewed prospectively collected data from 51 to 18 patients who underwent DTR and DFT, respectively, between September 2014 and December 2018. Short-term surgical outcomes, presence of reflux esophagitis, nutritional supplementation, medications, nutritional status (laboratory results and body composition analysis), and QoL measured preoperatively and at 1 year postoperatively were compared between both groups.

RESULTS

Both groups did not differ significantly in clinicopathological characteristics. The DFT as compared to the DTR group required significantly longer time for anastomosis (79.4 vs. 60.9 min, p < 0.001) and use of fewer staplers (3.39 vs. 6.86, p < 0.001). While the presence of endoscopic reflux esophagitis and iron/vitamin B₁₂ replacement were comparable, the DTR group showed a higher tendency of taking anti-reflux medications for reflux symptoms (DTR: 13.7% vs. DFT: 0.0%, p = 0.177). The DTR group lost significantly more weight (p = 0.038) and body fat (p = 0.009). QoL analysis showed significant deterioration in diarrhea, eating restriction, and taste problems in both groups (DTR group: p = 0.008, p < 0.001, p = 0.010, respectively, and DFT group: p = 0.017, p = 0.024, p = 0.034, respectively). However, only the DTR group showed significant deterioration in physical function (p = 0.009), role function (p = 0.033), nausea/vomiting (p = 0.041), appetite loss (p = 0.019), dysphagia (p = 0.001), pain (p = 0.025), and body image (p = 0.004).

CONCLUSIONS

Despite requiring a longer anastomosis time, performing DFT after LPG was shown to be an ideal reconstruction method in terms of better 1-year QoL and nutritional outcome. Further larger studies over longer postoperative periods are necessary to confirm our findings.

Correlation between healing type of lesion and recurrence in gastric neoplastic lesions after endoscopic submucosal dissection

BACKGROUND/AIMS

To date, there are few reports on the clinical association between healing pattern of lesion and local recurrence after endoscopic resection (ER). We examined the risk factors associated with local recurrence after endoscopic submucosal dissection (ESD) and the correlation between healing type of lesion and recurrence.

MATERIALS AND METHODS

We retrospectively analyzed medical records of 293 patients who underwent ESD of early gastric cancer or gastric adenoma between April 2010 and January 2012. We analyzed the relationship among factors such as age, location of lesion, size, pathologic diagnosis, presence of Helicobacter pylori (H. pylori), and healing types of ulcers in patients with local recurrence through follow-up endoscopic surveillance (1, 6, and 12 months after ESD).

RESULTS

We analyzed 141 patients except for patients who had not undergone surveillance endoscopy, H. pylori test, and ambiguous healing patterns. There were no significant correlations between local recurrences concerning sex, age, tumor size, location, and pathologic diagnosis. When the healing type of the ulcer was divided into hypertrophic polypoid type (9 cases (6.4%)), scar type (122 cases (86.5%)), and nodular type (10 cases (7.1%)), the scar type was found to be most common. A total of eight patients (5.7%) developed local recurrence, of which five were of nodular type and statistically significant (p=0.000).

CONCLUSION

The most common type of ulcer healing was scar type after ESD, but nodular type was associated with local recurrence. When we perform follow-up endoscopy after ESD, we should pay attention to the lesion that has nodular change of mucosal surface.

Characteristics of metachronous gastric neoplasms after curative endoscopic submucosal dissection for early gastric neoplasms

BACKGROUND

With the wide application of endoscopic submucosal dissection (ESD) for early gastric neoplasms, metachronous gastric neoplasms (MGN) have gradually become a concern. This study aimed to analyze the characteristics of MGN and evaluate the treatment and follow-up outcomes of MGN patients.

METHODS

A total of 814 patients were retrospectively enrolled. All these patients were treated by ESD for early gastric cancer or gastric dysplasia between November 2006 and September 2019 at The First Medical Center of Chinese People's Liberation Army General Hospital. The risk factors for MGN were analyzed using Cox hazard proportional model. Moreover, the cumulative incidence, the correlation of initial lesions and MGN lesions, and the treatment and follow-up outcomes of MGN patients were analyzed.

RESULTS

A total of 4.5% (37/814) of patients had MGN after curative ESD. The 3-, 5-, and 7-year cumulative incidences of MGN were 3.5%, 5.1%, and 6.9%, respectively, and ultimately reaching a plateau of 11.3% at 99 months after ESD. There was no significant correlation between initial lesions and MGN lesions in terms of gross type (P = 0.178), location (long axis: P = 0.470; short axis: P = 0.125), and histological type (P = 0.832). Cox multivariable analysis found that initial multiplicity was the only independent risk factor of MGN (hazard ratio: 4.3, 95% confidence interval: 2.0-9.4, P < 0.001). Seventy-three percent of patients with MGN were treated by endoscopic resection. During follow-up, two patients with MGN died of gastric cancer with lymph node metastasis. The disease-specific survival rate was significantly lower in patients with MGN than that in patients without MGN (94.6% vs. 99.6%, P = 0.006).

CONCLUSIONS

The MGN rate gradually increased with follow-up time within 99 months after curative gastric ESD. Thus, regular and long-term surveillance endoscopy may be helpful, especially for patients with initial multiple neoplasms.

The Incidence and Risk Factors for Metachronous Gastric Cancer in the Remnant Stomach after Gastric Cancer Surgery

Background/Aims

Less invasive surgical treatment is performed in East Asia to preserve postoperative digestive function and reduce complications such as postgastrectomy syndromes, but there is an issue of metachronous gastric cancer (GC) in the remaining stomach. This study aimed to analyze the incidence of metachronous GC and its risk factors in patients who had undergone partial gastrectomy.

Methods

A total of 3,045 GC patients who had undergone curative gastric partial resection at Seoul National University Bundang Hospital were enrolled and analyzed retrospectively for risk factors, including age, sex, smoking, alcohol, Helicobacterpylori status, family history of GC, histological type, and surgical method.

Results

Metachronous GC in the remaining stomach occurred in 35 of the 3,045 patients (1.1%) 23 in the distal gastrectomy group (18 with Billroth-I anastomosis, five with Billroth-II anastomosis), seven in the proximal gastrectomy (PG) group, and five in the pylorus-preserving gastrectomy (PPG) group. Univariate and multivariate Cox regression analyses showed that age ≥60 years (p=0.005) and surgical method used (PG or PPG, p<0.001) were related risk factors for metachronous GC, while male sex and intestinal type histology were potential risk factors.

Conclusions

Metachronous GC was shown to be related to older age and the surgical method used (PG or PPG). Regular and careful follow-up with endoscopy should be performed in the case of gastric partial resection, especially in patients with male sex and intestinal type histology as well as those aged ≥60 years undergoing the PG or PPG surgical method.

Molecular and pathological analyses of gastric stump cancer by next-generation sequencing and immunohistochemistry

Gastric stump cancer (GSC) has distinct clinicopathological characteristics from primary gastric cancer. However, the detailed molecular and pathological characteristics of GSC remain to be clarified because of its rarity. In this study, a set of tissue microarrays from 89 GSC patients was analysed by immunohistochemistry and in situ hybridisation. Programmed death ligand 1 (PD-L1) was expressed in 98.9% of tumour-infiltrating immune cells (TIICs) and 6.7% of tumour cells (TCs). Epstein–Barr virus (EBV) was detected in 18 patients (20.2%). Overexpression of human epidermal growth factor receptor 2 and deficiency of mismatch repair (MMR) protein expression were observed in 5.6% and 1.1% of cases, respectively. Moreover, we used next-generation sequencing to determine the gene mutation profiles of a subset of the 50 most recent patients. The most frequently mutated genes were TP53 (42.0%) followed by SMAD4 (18.0%) and PTEN (16.0%), all of which are tumour suppressor genes. A high frequency of PD-L1 expression in TIICs and a high EBV infection rate suggest immune checkpoint inhibitors for treatment of GSC despite a relatively low frequency of deficient MMR gene expression. Other molecular characteristics such as PTEN and SMAD4 mutations might be considered to develop new treatment strategies.

A case of gastric and duodenal mucosa-associated lymphoid tissue lymphoma with multiple gastric cancers: a case report

Background

Gastric mucosa-associated lymphoid tissue (MALT) lymphoma is often caused by Helicobacter pylori and has a good prognosis. Rarely, patients with MALT lymphoma may have gastric cancer and have a poor prognosis.

Case presentation

We herein report a case in which surgical treatment was achieved for a 72-year-old male patient with gastric and duodenal MALT lymphoma coexisting multiple gastric cancers. He underwent upper endoscopy for epigastric discomfort, which revealed mucosal erosion on the posterior wall of the middle body of the stomach, an elevated lesion on the duodenal bulb, and a raised tumor on the antrum of the stomach. He was diagnosed with gastric and duodenal MALT lymphoma with early gastric cancer. One month after H. pylori eradication, a second upper endoscopy revealed no improvement in the gastric or duodenal mucosa, and areas of strong redness with a shallow recess just below the cardia of the stomach. As a result, a diagnosis of gastric and duodenal MALT lymphoma with two gastric cancers was made. Total gastrectomy with proximal duodenum resection using intraoperative upper endoscopy and regional lymph node dissection was performed. Pathologically, gastric and duodenal MALT lymphoma and three gastric cancers were detected. Since one of them was an advanced cancer, he started taking S-1 after his general condition improved.

Conclusion

For early detection of gastric and duodenal MALT lymphoma or gastric cancer, appropriate upper endoscopy and a biopsy are important. It is necessary to select a suitable treatment, such as H. pylori eradication, endoscopic treatment, surgery, chemotherapy, and irradiation, according to the disease state.

Impact of the timing of Helicobacter pylori eradication on the risk of development of metachronous lesions after treatment of early gastric cancer: a population-based cohort study

BACKGROUND AND AIMS

Helicobacter pylori eradication can reduce the risk of metachronous lesions after the treatment of early gastric cancer. We aimed to analyze the impact of the timing of H pylori eradication on metachronous recurrence.

METHODS

Data of patients who underwent endoscopic resection or partial gastrectomy for early stage gastric cancer and received H pylori eradication therapy were obtained from the Korean National Health Insurance Service database. Patients were classified into 3 groups according to the timing of the prescription for H pylori eradication: preresection; within 1 year postresection; and >1 year postresection.

RESULTS

Among 19,767 patients, 7452 and 12,315 underwent endoscopic resection and surgery, respectively. The 5-year cumulative incidence of metachronous lesions after endoscopic resection was 14.0% in the preresection group, 12.3% in the within 1 year postresection group, and 16.9% in the >1 year postresection group. Surgery was performed in 1.2% of the preresection group, 1.3% of the within 1 year postresection group, and 2.9% of the >1 year postresection group. The within 1 year postresection group had a lower risk of development of metachronous lesions than the >1 year postresection group (hazard ratio [95% confidence interval]: after endoscopic resection, 0.79 [0.65-0.95]; after surgery, 0.39 [0.28-0.53]). The risk of development of metachronous lesions did not differ between the preresection and within 1 year postresection groups.

CONCLUSION

Prescription of H pylori eradication therapy within 1 year after gastric cancer treatment reduces the risk of development of metachronous gastric neoplasms compared with a late prescription of eradication therapy in patients undergoing endoscopic resection and those undergoing surgery.

Total Tumor Volume Should be Considered as an Important Prognostic Factor for Synchronous Multiple Gastric Cancer Patients with Curative Gastrectomy

Synchronous multiple gastric cancer (SMGC) was a special type of gastric cancer with relatively low incidence. This article was designed to demonstrate that the total tumor volume (TTV) should be treated as an important prognostic factor in SMGC patients with curative gastrectomy. This study retrospective analyzed 140 SMGC patients who received curative gastrectomy between December 2004 and December 2014 in our hospital. Clinicopathological features, preoperative evaluation, surgical treatment, and outcome parameters were reviewed and analyzed. This study applied univariate and multivariate analyses to identify the most significant prognostic factors. In the univariate analysis, the TTV, pT_TVNM, pN stage, pT of main tumor were all significant prognostic factors in SMGC patients (all P < 0.05). In the multivariate analysis, pN stage, TTV and pT_TVNM were confirmed to be independent prognostic factors (all P < 0.05). In the comparison of survival analysis, the pT_TVNM stage system (P < 0.05) was superior to the pTNM stage system (P > 0.05) in SMGC patients. In conclusion, the TTV should be considered as an independent prognostic factor in overall survival in SMGC patients who received curative gastrectomy. The pT_TVNM stage should be recommended as a suitable staging system for SMGC patients.

The Mexican consensus on the detection and treatment of early gastric cancer

Gastric cancer is one of the most frequent neoplasias in the digestive tract and is the result of premalignant lesion progression in the majority of cases. Opportune detection of those lesions is relevant, given that timely treatment offers the possibility of cure. There is no consensus in Mexico on the early detection of gastric cancer, and therefore, the Asociación Mexicana de Gastroenterología brought together a group of experts and produced the "Mexican consensus on the detection and treatment of early gastric cancer" to establish useful recommendations for the medical community. The Delphi methodology was employed, and 38 recommendations related to early gastric cancer were formulated. The consensus defines early gastric cancer as that which at diagnosis is limited to the mucosa and submucosa, irrespective of lymph node metástasis. In Mexico, as in other parts of the world, factors associated with early gastric cancer include Helicobacter pylori infection, a family history of the disease, smoking, and diet. Chromoendoscopy, magnification endoscopy, and equipment-based image-enhanced endoscopy are recommended for making the diagnosis, and accurate histopathologic diagnosis is invaluable for making therapeutic decisions. The endoscopic treatment of early gastric cancer, whether dissection or resection of the mucosa, should be preferred to surgical management, when similar oncologic cure results can be obtained. Endoscopic surveillance should be individualized.

Surgical resection of gastric stump cancer following proximal gastrectomy for adenocarcinoma of the esophagogastric junction

BACKGROUND

Proximal gastrectomy (PG) is performed widely as a function-preserving operation for early gastric cancer located in the upper third of the stomach and is an important function-preserving approach for esophagogastric junction (EGJ) adenocarcinoma. The incidence of gastric stump cancer (GSC) after PG is increasing. However, little is known about the GSC following PG because very few studies have been conducted on the disease.

AIM

To clarify clinicopathologic features, perioperative complications, and long-term survival rates after the resection of GSC following PG.

METHODS

Data for patients with GSC following PG for adenocarcinoma of the EGJ diagnosed between January 1998 and December 2016 were retrospectively reviewed. Multivariate analysis was performed to identify factors associated with overall survival (OS). GSC was defined in accordance with the Japanese Gastric Cancer Association.

RESULTS

A total of 35 patients were identified. The median interval between the initial PG and resection of GSC was 4.9 (range 0.7-12) years. In 21 of the 35 patients, the tumor was located in a nonanastomotic site of the gastric stump. Total gastrectomy was performed in 27 patients; the other 8 underwent partial gastrectomy. Postoperative complications occurred in 6 patients (17.1%). The tumor stage according to the depth of tumor invasion was T1 in 6 patients, T2 in 3 patients, T3 in 9 patients, and T4 in 17 patients. Lymph node metastasis was observed in 18 patients. Calculated 1-, 3-, and 5-year OS rates were 86.5%, 62.3%, and 54.2%, respectively. Multivariate analysis showed advanced T stage to be associated with OS.

CONCLUSION

This study reveals the characteristics of GSC following PG for adenocarcinoma of the EGJ and suggests that a surgical approach can lead to a satisfactory outcome.

Clinical outcomes of endoscopic treatment for gastric epithelial neoplasm in remnant stomach after distal gastrectomy

BACKGROUNDS/AIM

We aimed to evaluate the feasibility of endoscopic treatment for gastric epithelial neoplasm in the remnant stomach after distal gastrectomy and compared the clinical outcomes by tumor location and endoscopic treatment modality.

METHODS

We reviewed the data of patients who underwent endoscopic treatment for gastric epithelial neoplasms in the remnant stomach after distal gastrectomy between January 1996 and August 2013. The treatments included endoscopic resection or argon plasma coagulation.

RESULTS

Herein, 107 patients (median age, 65.1 years; 92 men) encompassing 117 cases of gastric neoplasms in the remnant stomach after distal gastrectomy were endoscopically treated. Forty of these lesions were located at anastomotic sites; they were treated with endoscopic resection in 29 cases (72.5%) and argon plasma coagulation in 11 cases (27.5%). For 77 lesions located on the non-anastomotic site, endoscopic resection was performed in 68 cases (88.4%) and argon plasma coagulation was performed in nine cases (11.7%; p = 0.031). The mean endoscopic resection duration was significantly longer in the anastomotic site group than in the non-anastomotic site group (43.6 vs. 26.3 min, p = 0.018). Recurrence was observed in five (12.8%) patients in the former and in one (1.3%) in the latter (p = 0.015); all the patients were successfully retreated with endoscopic resection or APC.

CONCLUSIONS

Endoscopic treatment for gastric epithelial neoplasm in a remnant stomach after distal gastrectomy is effective and safe. However, closely monitoring for recurrence should be conducted, particularly when the tumor is located at the anastomotic site.

Comparison of laparoscopic proximal gastrectomy with double-tract reconstruction and laparoscopic total gastrectomy in terms of nutritional status or quality of life in early gastric cancer patients

BACKGROUND

This study aimed to evaluate the surgical outcomes of laparoscopic proximal gastrectomy (LPG) reconstructed by the double-tract method in comparison to those of laparoscopic total gastrectomy (LTG).

METHODS

A retrospective review of the prospectively established database identified early gastric cancer patients who underwent LPG (n = 34) or LTG (n = 46) between January 2011 and December 2015. Baseline characteristics and surgical outcomes including postoperative complications, changes in body composition, nutritional status, and quality of life (QOL) after surgery were compared between the LPG and LTG patients.

RESULTS

Operating time was significantly longer in the LTG group (240.7 ± 43.9 vs. 211.7 ± 32.8 min, p = 0.007). The incidence of grade II or more complications and the hospital stay were comparable between the groups. There was no significant difference between the groups in terms of body composition using a bioelectrical impedance method in 1 year postoperatively. Nutritional status assessed by serum hemoglobin, iron, vitamin B12, albumin, total protein, and total cholesterol levels and postoperative changes in quality of life up to 2 years after surgery were also similar between the groups. Vitamin B12 supplementation was required in 75.4% of the patients in the LTG group and 46.5% in the LPG group within 2 years after surgery (p = 0.005).

CONCLUSION

LPG with double-tract reconstruction appears superior in preventing vitamin B12 deficiency compared to LTG, particularly after 1 year after the surgery, although it offered little benefit in terms of postoperative body composition changes and QOL.

Clinicopathological characteristics and prognostic factors of remnant gastric cancer: A single-center retrospective analysis of 90 patients

BACKGROUND

The prognosis of remnant gastric cancer (RGC) is significantly poor. However, the mechanism and some clinical features of RGC have not been fully understood and are still under debate.

MATERIALS AND METHODS

From January 2000 to January 2014, 90 RGC patients were enrolled in this retrospective study. Patients were divided into two groups according to primary disease. Clinicopathological features and survival outcomes were compared between two groups.

RESULTS

A total of 34 (37.8%) patients were diagnosed with remnant gastric cancer following benign disease (RGCB) and 56 (62.2%) were diagnosed with remnant gastric cancer following malignant disease (RGCM). The mean time interval from the primary operation to the development of RGC was 12.5 ± 13.3 years in all RGC patients. The mean time interval in RGCB was significantly longer than that in RGCM (P < 0.01). The 1-, 2-, and 3- year overall survival rates of all patients were 56.1%, 38.2% and 33.2%, respectively. Univariate analysis indicated that tumor size, curability, histology type, serosa invasion, nodal involvement and distant metastasis were prognostic factors for RGC. The multivariate Cox regression analysis revealed that distant metastasis was an independent prognostic factor for RGC.

CONCLUSION

RGC occurred earlier in patients with gastrectomy for primary malignant disease than for primary benign disease, even though the primary disease made no difference to the survival of RGC. Nonetheless, RGC patients experienced dismal overall survival. Therefore, early diagnosis plays a significant role in successfully carrying out curative resection and improving the prognosis for RGC.

Long-term outcome of endoscopic submucosal dissection is comparable to that of surgery for early gastric cancer: a propensity-matched analysis

BACKGROUND

Data concerning the long-term outcomes of endoscopic submucosal dissection (ESD) versus surgery for early gastric cancer (EGC) are limited. We aimed to compare the long-term outcomes of ESD and surgery for patients with EGC.

METHODS

Data were reviewed from patients treated by ESD or surgery for EGC in 2005-2010. The primary outcome was overall survival (OS). Secondary outcomes were disease-specific survival (DSS), disease-free survival (DFS), recurrence-free survival (RFS), treatment-related complications, and hospital stay duration.

RESULTS

Among 617 patients, 342 underwent ESD and 275 underwent surgery. The 5-year OS rates were similar between the ESD group and the surgery group (96.9% vs 98.1%, P = 0.581). In a propensity-score-matched analysis of 117 pairs, there were no significant differences in the OS rates (96.5% vs 99.1%, P = 0.125) and DSS rates (100% vs 99.1%, P = 0.317) between the ESD group and the surgery group. The ESD group had a significantly lower DFS rate (90.3% vs 98.0%, P = 0.002), a significantly lower RFS rate (95.1% vs 98.0%, P = 0.033), a significantly higher early complication rate (6.7% vs 1.5%, P < 0.001), a significantly lower late complication rate (0% vs 9.1%, P < 0.001), and a significantly shorter median hospital stay (3 days vs 10 days, P < 0.001) than the surgery group.

CONCLUSIONS

ESD and surgery have comparable OS rates in patients with EGC. ESD has benefits, including a lower late complication rate and shorter hospital stay. However, RFS and DFS rates might be lower after ESD than after surgery.

Metachronous Gastric Cancer Following Curative Endoscopic Resection of Early Gastric Cancer

This review article summarizes knowledge about metachronous gastric cancer (MGC) occurring after curative endoscopic resection (ER) of early gastric cancer (EGC), treatment outcomes of patients who developed MGC, and efficacy of Helicobacter pylori eradication to prevent MGC. The incidence of MGC following curative ER increases over time and is higher than in patients undergoing gastrectomy. Increasing age and multifocal EGC are independent risk factors for developing MGC. An MGC following curative ER is usually a small (<20 mm) and differentiated intramucosal cancer. Most MGC lesions are found at an early stage on semiannual or annual surveillance endoscopy and are successfully treated by further ER, with excellent long-term outcomes. Eradication of H. pylori may reduce the risk of MGC following ER of EGC, but further prospective studies with long-term outcomes are required. Surveillance endoscopy following gastric ER should be continued indefinitely, due to the risk of MGC even after successful H. pylori eradication. Risk stratification and tailored endoscopic surveillance schedules need to be developed.

Comparative study between endoscopic submucosal dissection and surgery in patients with early gastric cancer

BACKGROUND

Endoscopic submucosal dissection (ESD) is accepted as a standard treatment in patients with early gastric cancer (EGC) who have a negligible risk of lymph node metastasis. The aim of this study was to compare the short-term and long-term outcomes between ESD and surgery in patients with EGC that fulfilled the expanded indication of ESD on their final pathologic report.

METHODS

We reviewed the clinical data of patients who underwent gastric ESD and surgery between January 2007 and December 2012. Patients with pathologically confirmed EGC that fulfilled the expanded indication of ESD on their final pathologic report were analyzed.

RESULTS

Among 2023 patients, 817 (40.4%) underwent ESD and 1206 (59.6%) underwent surgery. The proportion of cases meeting the absolute indication was significantly higher in the ESD group than in the surgery group (66.0 vs. 26.2%). Lesions on the middle third, >3 cm in size, flat or depressed, and of undifferentiated histology were significantly more common in the surgery group than in the ESD group. The ESD group showed lower acute complication rates [8.1% (66 of 817) vs. 18.1% (218 of 1206), P ≤ 0.001] and procedure-related mortality [0 vs. 0.3% (4 of 1206), P = 0.153] than the surgical group. The annual incidence of recurrent gastric cancer was 2.18% in the ESD group and 0.19% in the surgery group. The 5-year overall and disease-specific survival rates were not significantly different between the ESD group and the surgery group (overall survival: 96.4 vs. 97.2%, P = 0.423; disease-specific survival: 99.6 vs. 99.2%, P = 0.203).

CONCLUSIONS

Although EGC lesions had poorer features in the surgery group than in the ESD group, ESD was comparable to surgery for EGCs that fulfilled the expanded indication of ESD, with lower rates of acute complication and comparable overall survival.

Endoscopic Submucosal Dissection of Gastric Epithelial Neoplasms after Partial Gastrectomy: A Single-Center Experience

Aims

To investigate the feasibility and safety of endoscopic submucosal dissection (ESD) of gastric epithelial neoplasms in the remnant stomach (GEN-RS) after various types of partial gastrectomy.

Methods

This study included 29 patients (31 lesions) who underwent ESD for GEN-RS between March 2006 and August 2016. Clinicopathologic data were retrieved retrospectively to assess the therapeutic ESD outcomes, including en bloc and complete resection rates and procedure-related adverse events.

Results

The en bloc, complete, and curative resection rates were 90%, 77%, and 71%, respectively. The types of previous gastrectomy, tumor size, macroscopic type, and tumor histology were not associated with incomplete resection. Only tumors involving the suture lines from the prior partial gastrectomy were significantly associated with incomplete resection. The procedure-related bleeding and perforation rates were 6% and 3%, respectively; none of the adverse events required surgical intervention. During a median follow-up period of 25 months (range, 6–58 months), there was no recurrence in any case.

Conclusions

ESD is a safe and feasible treatment for GEN-RS regardless of the previous gastrectomy type. However, the complete resection rate decreases for lesions involving the suture lines.

Incidence and impact of scheduled endoscopic surveillance on recurrence after curative endoscopic resection for early gastric cancer

BACKGROUND AND AIMS

The aim of this study was to identify the incidence of recurrent lesions after endoscopic submucosal dissection (ESD) and to determine whether scheduled endoscopic surveillance might control their development and treatment.

METHODS

We reviewed the clinical data of patients who underwent gastric ESD between March 2007 and April 2014.

RESULTS

A total of 1347 patients who underwent curative ESD for early gastric cancer that met the expanded indication for ESD were analyzed. Of these, recurrence at the previous ESD site occurred in 39 patients, whereas recurrence in the stomach at a site other than the ESD site occurred in 102 patients. Older age, intestinal metaplasia, flat or depressed lesions, and ESD criteria were associated with recurrence in the stomach in places other than the ESD site. The annual incidence was .84% for recurrence at the previous ESD site and 2.48% for recurrence in the stomach at other than the ESD site. In cases of local recurrence and metachronous lesions, there was a significant difference between the short- and long-surveillance interval group (≤12 months vs >12 months) in the proportions of recurrent adenocarcinoma (31.9% vs 60.9%, P = .021), additional gastrectomy (7.1% vs 46.2%, P = .033), and size (8.92 ± 4.17 mm vs 18.08 ± 10.47 mm, P = .010).

CONCLUSIONS

Scheduled endoscopy surveillance is necessary for detecting recurrent lesions. In addition, scheduled endoscopy surveillance might help to detect recurrent lesions at a stage early enough for a curative resection.

Second primary pancreatic ductal carcinoma in the remnant pancreas after pancreatectomy for pancreatic ductal carcinoma: High cumulative incidence rates at 5 years after pancreatectomy

OBJECTIVES

The aim of this study was to determine the incidence rate and clinical features of second primary pancreatic ductal carcinoma (SPPDC) in the remnant pancreas after pancreatectomy for pancreatic ductal carcinoma (PDC).

METHODS

Data of patients undergoing R0 resection for PDC at a single high-volume center were reviewed. SPPDC was defined as a tumor in the remnant pancreas after R0 resection for PDC, and SPPDC met at least one of the following conditions: 1) the time interval between initial pancreatectomy and development of a new tumor was 3 years or more; 2) the new tumor was not located in contact with the pancreatic stump. We investigated the clinical features and treatment outcomes of patients with SPPDC.

RESULTS

This study included 130 patients who underwent surgical resection for PDC between 2005 and 2014. Six (4.6%) patients developed SPPDC. The cumulative 3- and 5-year incidence rates were 3.1% and 17.7%, respectively. Four patients underwent remnant pancreatectomy for SPPDC. They were diagnosed with the disease in stage IIA or higher and developed recurrence within 6 months after remnant pancreatectomy. One patient received carbon ion radiotherapy and survived 45 months. One patient refused treatment and died 19 months after the diagnosis of SPPDC.

CONCLUSIONS

The incidence rate of SPPDC is not negligible, and the cumulative 5-year incidence rate of SPPDC is markedly high. Post-operative surveillance of the remnant pancreas is critical for the early detection of SPPDC, even in long-term survivors after PDC resection.

Risk factors for radical reoperation in patients with remnant gastric cancer

AIM: To identify the risk factors for radical reoperation in patients with remnant gastric cancer.

METHODS: A retrospective analysis was performed of clinical data for 60 patients with recurrent gastric stump cancer who underwent a second surgery from January 2009 to January 2015 at Ningxia Guyuan Hospital. Risk factors for radical reoperation were identified.

RESULTS: Of 60 patients, 26 (43.33%) were treated by radical surgery, 16 (26.67%) were treated by palliative surgery, 15 (25.00%) by gastric bypass surgery and jejunostomy, and 3 (5.00%) did not underwent surgery. Univariate analysis showed that age, gastrointestinal reconstruction, TNM stage at initial surgery, N stage at initial surgery, lymph node dissection, symptomatic recurrence, interval between recurrence and the second surgery, time to recurrence, adjuvant chemotherapy, Helicobacter pylori (H. pylori) infection, low stomach acid, and histology were significantly associated with a second radical surgery (P < 0.05). Multivariate Logistic regression analysis showed that age > 60 years, N stage at initial surgery, TNM stage at initial surgery, symptomatic relapse, H. pylori infection, histological type and low stomach acid were independent risk factors for a second radical surgery (P < 0.05).

CONCLUSION: Age > 60 years, TMN stage III at initial surgery, N0 stage at initial surgery, symptomatic relapse, H. pylori infection, low acid and histological type are independent risk factors for a second radical surgery in patients with remnant gastric cancer.

Plasma membrane proteomic analysis of human Gastric Cancer tissues: revealing flotillin 1 as a marker for Gastric Cancer

Background

Gastric cancer remains the second leading cause of cancer-related deaths in the world. Successful early gastric cancer detection is hampered by lack of highly sensitive and specific biomarkers. Plasma membrane proteins participate and/or have a central role in the metastatic process of cancer cells and are potentially useful for cancer therapy due to easy accessibility of the targets.

Methods

In the present research, TMT method followed by mass spectrometry analysis was used to compare the relative expression levels of plasma membrane proteins between noncancer and gastric cancer tissues.

Results

Of a total data set that included 501 identified proteins, about 35% of the identified proteins were found to be plasma membrane and associated proteins. Among them, 82 proteins were at least 1.5-fold up- or down-regulated in gastric cancer compared with the adherent normal tissues.

Conclusions

A number of markers (e.g. annexin A6, caveolin 1, epidermal growth factor receptor, integrin beta 4) were previously reported as biomarkers of GC. Additionally, several potential biomarkers participated in endocytosis pathway and integrin signaling pathways were firstly identified as differentially expressed proteins in GC samples. Our findings also supported the notion that flotillin 1 is a potential biomarker that could be exploited for molecular imaging-based detection of gastric cancer. Together, the results show that subcellular proteomics of tumor tissue is a feasible and promising avenue for exploring oncogenesis.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-015-1343-5) contains supplementary material, which is available to authorized users.

Efficacy and long-term outcome of pre-emptive endoscopic resection and surgery for multiple synchronous gastric cancers

BACKGROUND

In cases of synchronous gastric cancers (SGC) that include one for surgical indication and another for endoscopic resection (ER) in two different regions of the stomach, patients can avoid total gastrectomy and undergo subtotal gastrectomy following successful pre-emptive ER. The aim of this study was to evaluate the feasibility and efficacy of pre-emptive endoscopic resection and surgery (PRES) with curative intent for such SGCs.

METHODS

Between September 2002 and December 2012, 34 patients with SGCs (72 lesions) underwent PRES. Our institutional principals of PRES ensure the following: (1) treatment with curative intent, (2) multiple lesions indicated for ER and surgery, (3) evasion of TG following successful pre-emptive ER, (4) exclusion of type 4 and large type 3 (>80 mm) tumors, and (5) nonemergent cases such as hemorrhage, perforation, and obstruction. Clinicopathological characteristics and technical data were evaluated for all patients, and long-term outcomes were analyzed in patients who obtained curative ER and underwent subtotal gastrectomy.

RESULTS

Curative ER was obtained in 31 patients (91.1 %), and subtotal gastrectomy was performed a median of 44 days after ER. Final stages were as follows: stage I, 25 patients (80.6 %); stage II, four patients (12.9 %); stage III, one patient (3.2 %); and stage IV, one patient (3.2 %). The 5-year overall and cause-specific survival rates were 96.3 % (95 % confidence interval 89.4-100 %) and 100 %, respectively.

CONCLUSIONS

PRES was feasible and effective as the first treatment of choice for multiple SGCs. PRES enables minimally invasive surgery with promising oncological outcomes.

Increased incidence of secondary gastric neoplasia in patients with early gastric cancer and coexisting gastric neoplasia at the initial endoscopic evaluation

BACKGROUND AND AIMS

Multiple synchronous gastric cancers are found in up to 14% of affected patients. The aim of this study was to determine the incidence of secondary gastric neoplasia including missed synchronous gastric neoplasia in this patient group compared with that after a single cancer resection.

PATIENTS AND METHODS

Four hundred and forty patients who underwent endoscopic resection for early gastric cancer (EGC) were divided into two groups: those with or without synchronous gastric neoplasia at the initial assessment. Secondary gastric neoplasia was defined as missed synchronous gastric neoplasia or metachronous gastric neoplasia. We compared the clinicopathological characteristics and the incidence of secondary gastric neoplasia between the two groups.

RESULTS

Synchronous gastric neoplasias were found in 34 patients (7.7%) at the initial endoscopic examination of EGC. Secondary gastric neoplasias were found in 67 of 440 patients (15.2%) during the follow-up period (median 24.0 months). The incidence of secondary gastric neoplasia and missed synchronous gastric neoplasia was higher in those patients with synchronous gastric neoplasia than in those with a solitary EGC at the initial treatment (P<0.01). Between the two groups, the risk of the secondary neoplasia was significantly higher within 1 year after endoscopic resection (P<0.01), but not after 1 year (P=0.20).

CONCLUSION

EGC with synchronous gastric neoplasia at the initial endoscopic examination was associated with an increased risk of secondary gastric neoplasia. These patients should be evaluated carefully with a shorter interval after the initial treatment.