Liver-directed treatments for liver metastasis from gastric adenocarcinoma: comparison between liver resection and radiofrequency ablation

Debate: Improvements in Systemic Therapies for Liver Metastases Will Increase the Role of Locoregional Treatments

The benefit of resection of liver metastases depends on primary diseases. Neuroendocrine tumors are associated with favorable prognosis after resection of liver metastases. Gastric cancer has worse tumor biology, and resection of gastric liver metastases should be performed in selected patients. A multidisciplinary approach is well established for colorectal liver metastases (CLMs). Resection remains the only curative treatment of CLM. Chemotherapy and molecular-targeted therapy have improved survival in unresectable metastatic colorectal cancer. Understanding of the following two strategies, conversion therapy and two-stage hepatectomy, are important to make this patient group to be candidates for curative-intent surgery.

Is There a Role for Locoregional Therapies for Non-colorectal Gastrointestinal Malignancies?

The liver is the most common site of metastases from solid gastrointestinal tract tumors. Over the past few decades, the role of locoregional therapies, resection and thermal ablation, for neuroendocrine and colorectal liver metastases has been widely studied. However, for liver metastases originating from other gastrointestinal organs, the role of locoregional treatment remains unclear. This review summarizes and discusses the available evidence regarding benefits, risks, and indications for locoregional therapies for non-colorectal and non-neuroendocrine gastrointestinal liver metastases, highlighting the importance of multidisciplinary approach and patient selection.

Combination of clinical and spectral-CT iodine concentration for predicting liver metastasis in gastric cancer: a preliminary study

PURPOSE

This study aimed to determine the diagnostic efficacy of various indicators and models for the prediction of gastric cancer with liver metastasis.

METHODS

Clinical and spectral computed tomography (CT) data from 80 patients with gastric adenocarcinoma who underwent surgical resection were retrospectively analyzed. Patients were divided into metastatic and non-metastatic groups based on whether or not to occur liver metastasis, and the region of interest (ROI) was measured manually on each phase iodine map at the largest level of the tumor. Iodine concentration (IC), normalized iodine concentration (nIC), and clinical data of the primary gastric lesions were analyzed. Logistic regression analysis was used to construct the clinical indicator (CI) and clinical indicator-spectral CT iodine concentration (CI-Spectral CT-IC) Models, which contained all of the parameters with statistically significant differences between the groups. Receiver operating characteristic (ROC) curves were constructed to evaluate the accuracy of the models.

RESULTS

The metastatic group showed significantly higher levels of Cancer antigen125 (CA125), carcinoembryonic antigen (CEA), IC, and nIC in the arterial phase, venous phase, and delayed phase than the non-metastatic group (all p < 0.05). Normalized iodine concentration Venous Phase (nICVP) exhibited a favorable performance among all IC and nIC parameters for forecasting gastric cancer with liver metastasis (area under the curve (AUC), 0.846). The combination model of clinical data with significant differences and nICVP showed the best diagnostic accuracy for predicting liver metastasis from gastric cancer, with an AUC of 0.897.

CONCLUSION

nICVP showed the best diagnostic efficacy for predicting gastric cancer with liver metastasis. Clinical Indicators-normalized ICVP model can improve the prediction accuracy for this condition.

Genomic biology and therapeutic strategies of liver metastasis from gastric cancer

The liver is a frequent site of metastasis in advanced gastric cancer (GC). Despite significant advancements in diagnostic and therapeutic techniques, the overall survival rate for patients afflicted with gastric cancer liver metastasis (GCLM) remains dismally low. Precision oncology has made significant progress in identifying therapeutic targets and enhancing our understanding of metastasis mechanisms through genome sequencing and molecular characterization. Therefore, it is crucial to have a comprehensive understanding of the various molecular processes involved in GCLM and the fundamental principles of systemic therapy to develop new treatment approaches. This paper aims to review recent findings on the diagnosis, potential biomarkers, and therapies targeting the multiple molecular processes of GCLM, with the goal of improving treatment strategies for patients with GCLM.

Surgical treatment for liver metastasis from gastric cancer: A systematic review and meta-analysis of long-term outcomes and prognostic factors

Chemotherapy is the mainstay treatment for liver metastasis from gastric cancer. However, some retrospective studies and meta-analyses have indicated the efficacy of hepatectomy, which is an aggressive treatment option. However, the optimal selection criteria for hepatectomy and the role of perioperative chemotherapy remain unclear. Therefore, a meta-analysis of studies on hepatectomy was performed to assess the impact of various factors on overall survival (OS). A systematic review was conducted in accordance with the PRISMA criteria using studies published until 2022. The primary outcome was the hazard ratio (HR) for OS. Comparisons were made between hepatectomy and nonhepatectomy, solitary and multiple metastases, synchronous and metachronous metastases, treatment with and without neoadjuvant chemotherapy, and treatment with and without adjuvant chemotherapy. A total of 50 studies involving 1966 patients who underwent hepatectomy were included in the analysis. The meta-analysis showed a 5-year OS rate of 25 %. A meta-analysis comparing hepatectomy with nonhepatectomy showed an HR of 0.2 for hepatectomy. A meta-analysis comparing solitary and multiple metastases showed a trend toward better OS in patients with solitary metastases (odds ratio [OR]: 0.35). A meta-analysis comparing synchronous and metachronous metastases showed favorable OS for patients with metachronous metastases (OR: 0.66). A meta-analysis comparing neoadjuvant chemotherapy with no neoadjuvant chemotherapy showed no difference in OS. In contrast, a meta-analysis comparing adjuvant chemotherapy with no adjuvant chemotherapy showed better OS for adjuvant chemotherapy (OR: 0.39). This retrospective study indicates that hepatectomy may benefit patients with liver metastases from gastric cancer, particularly those with solitary and metachronous metastases.

High serum alpha-fetoprotein and positive immunohistochemistry of alpha-fetoprotein are related to poor prognosis of gastric cancer with liver metastasis

Liver metastasis in gastric cancer is incurable. Alpha-fetoprotein-producing gastric cancer has a poor prognosis and is prone to liver metastasis. We investigated the association between preoperative serum alpha-fetoprotein levels, liver metastasis, and expression of primitive enterocyte phenotype markers. We reviewed the medical records of 401 patients with gastric cancer who underwent curative surgical resection and immunohistochemically evaluated the primitive phenotype markers. The preoperative serum alpha-fetoprotein levels were elevated and normal in 8 and 393 patients, respectively. Liver metastasis was more frequent in patients with higher preoperative alpha-fetoprotein levels. The 5-year postoperative recurrence-free survival and overall survival rates were significantly worse in patients with higher preoperative serum alpha-fetoprotein levels. Although alpha-fetoprotein and Glypican3 and Spalt-like transcription factor 4 tended to be stained with high preoperative serum alpha-fetoprotein levels, these markers were also positive in some patients with normal alpha-fetoprotein levels. In summary, patients with gastric cancer and high preoperative serum alpha-fetoprotein levels have a poor prognosis and high incidence of liver metastasis. Alpha-fetoprotein can help detect liver metastasis relating to the primitive enterocyte phenotype.

The Japanese nationwide cohort data of proton beam therapy for liver oligometastasis in esophagogastric cancer patients

A nationwide multicenter cohort study on particle therapy was launched by the Japanese Society for Radiation Oncology in Japan in May 2016. We analyzed the outcome of proton beam therapy (PBT) for liver oligometastasis of esophagogastric cancers. Cases in which PBT was performed at all PBT facilities in Japan between May 2016 and February 2019 were enrolled. The patients were selected based on the following criteria: controlled primary cancer, liver recurrence without extrahepatic tumors and no more than three liver lesions. Twenty-two males and two females with a median age of 69 (range, 52-80) years and 35 lesions were included. This study included 6 patients with esophageal and 18 patients with gastric cancer. The median lesion size, fraction size and biological effective dose (BED)10 were 32 (7-104) mm, 3.8 gray (relative biological effect)/fractions (Gy (RBE)/fr) (2-8 Gy (RBE)/fr) and 96.9 (88.8-115.2) Gy, respectively. The median follow-up period was 18 (4-47) months. The 1-, 2- and 3-year overall survival (OS) rates were 75, 51.8 and 45.3%, respectively, and the median OS was 25.3 months. The 1-, 2- and 3-year cumulative local recurrence (LR) rates were 3, 6 and 6%, respectively. Patients' age (P < 0.01), performance status (P = 0.017) and tumor size (P = 0.024) were significant OS-related factors. No Grade 3 or higher adverse events (AEs) were observed. Owing to the low incidence of AEs and the low LR cumulative incidence, PBT is a feasible option for liver oligometastasis of esophagogastric cancers.

Comparison of the efficacy between immunochemotherapy and chemotherapy in gastric cancer accompanied with synchronous liver metastases: A real-world retrospective study

BACKGROUND

Few studies have investigated the efficacy of comprehensive therapies, including immunotherapy, for gastric cancer with synchronous liver metastases (GCLM). We retrospectively compared the effect of immunochemotherapy and chemotherapy alone as conversion therapies on the oncological outcomes of patients with GCLM.

METHODS

The clinicopathological data of 100 patients with GCLM from February 2017 to October 2021 at our institution were retrospectively analyzed. Patients were divided into immunochemotherapy (n = 33) and chemotherapy-alone (n = 67) groups.

RESULTS

Baseline clinicopathological data did not differ significantly between the two groups. The immunochemotherapy group had a higher overall response rate (59.4% vs. 44.0%, p = 0.029) and disease control rate (71.9% vs. 49.2%, p = 0.036) than the chemotherapy group. The immunochemotherapy group showed better tumor regression in the gastric mass, metastatic lymph nodes, and liver lesions than the chemotherapy group. Ten (30.3%) patients in the immunochemotherapy group and 13 (19.4%) patients in the chemotherapy group underwent surgery after conversion therapy. However, the difference was not statistically significant. The overall survival (OS) and progression-free survival (PFS) rates were better in the immunochemotherapy group than in the chemotherapy group. Treatment-related adverse events occurred in 24 (72.7%) and 47 (70.1%) patients in the immunochemotherapy and chemotherapy groups, respectively.

CONCLUSIONS

As a conversion therapy for GCLM, immunotherapy yielded better primary and metastatic tumor regression and survival benefits, with no increase in adverse events compared to chemotherapy.

Gastric cancer clinical characteristics and their altered trends in South China: An epidemiological study with 2,800 cases spanning 26 years

BACKGROUND

Gastric cancer (GC) is a serious threat to human health. The clinical GC characteristics in China may be impacted by changes in people's lifestyles and the promotion of early GC (EGC) screening. The present study aims to evaluate the recent trends of GC characteristics in South China and search for hazardous factors limiting the survival time of GC patients.

METHODS

Data on GC patients that were hospitalized in the Department of Digestive Center, the First Affiliated Hospital, Sun Yat-sen University, from 1994 to 2019 were collected and divided into two categories according to the time when the EGC screening began in China: the PRE group (previous 13 years, 1994-2006) and the PAS group (past 13 years, 2007-2019).

RESULTS

We found that, although the 5-year survival rate increased in the PAS group compared with the PRE group (P < 0.0001), patients with age ≥60 years or Borrmann type IV still had a worse prognosis. In the PAS group, the larger percentages of elderly patients and patients with Borrmann type IV in the lymphatic metastases (N1) group (41.0% vs. 51.1%, P = 0.0014) and stage IV subgroup (20.7% vs. 32.2%, P = 0.016), respectively, when compared with the PRE group, may have contributed to the poor outcome of GC. By comparing the odds ratio (OR) of 5-year overall survival (OS) in the two 13-year periods, female sex and T2 turned into risk factors because of a greater proportion of Borrmann type IV or elderly patients in the PAS group (OR = 0.983, 95% CI = 0.723-1.336 vs. OR = 1.277, 95% CI = 1.028-1.586 and OR = 1.545, 95% CI = 0.499-4.775 vs. OR = 2.227, 95% CI = 1.124-4.271, respectively).

CONCLUSIONS

Despite the GC epidemiology changes, the overall prognosis of GC patients has improved in South China. However, old age and Borrmann type IV are still the major restrictions affecting the survival of GC patients, a situation which calls for additional attention.

Is hepatic resection justified for non-colorectal non-neuroendocrine liver metastases? A systematic review and meta-analysis

BACKGROUND

Hepatic resection (HR) is effective for colorectal or neuroendocrine liver metastases. However, the role of HR for non-colorectal non-neuroendocrine liver metastases (NCNNLM) is unknown. This study aims to perform a systematic review and meta-analysis on long-term clinical outcomes after HR for NCNNLM.

METHODS

electronic search was performed to identify relevant publications using PRISMA and MOOSE guidelines. Primary outcomes were 3- and 5-year overall survival (OS) and disease-free survival (DFS). Secondary outcomes were post-operative morbidity and 30-day mortality.

RESULTS

There were 40 selected studies involving 5696 patients with NCNNLM undergone HR. Pooled data analyses showed that the 3- and 5-year OS were 40% (95% CI 0.35-0.46) and 32% (95% CI 0.29-0.36), whereas the 3- and 5-year DFS were 28% (95% CI 0.21-0.36) and 24% (95% CI 0.20-0.30), respectively. The postoperative morbidity rate was 28%, while the 30-day mortality was 2%. Subgroup analysis on HR for gastric cancer liver metastasis revealed the 3-year and 5-year OS of 39% and 25%, respectively.

CONCLUSIONS

HR for NCNNLM may achieve satisfactory survival outcome in selected patients with low morbidities and mortalities. However, more concrete evidence from prospective study is warrant in future.

Prognostic role of myeloid-derived tumor-associated macrophages at the tumor invasive margin in gastric cancer with liver metastasis (GCLM): a single-center retrospective study

BACKGROUND

Liver metastasis is one of the important factors leading to poor prognosis of gastric cancer. According to the classic "seed soil theory", it is speculated that the liver microenvironment at the invasion margin of gastric cancer liver metastases (GCLM) may have a crucial impact on tumor progression. However, few studies had stated the correlation between the patients' prognosis and the densities of stromal cells infiltrating into the invasive margin, where our retrospective study designed to identify the role of infiltrating macrophages on the prognosis of GCLM as a reliable supplement of predictive tumor markers.

METHODS

The material consisted of a group of 72 gastric cancer (GC) patients with liver metastasis diagnosed from February 2015 and December 2020. The CD68+, CD206+, and Clec4f+ macrophages in their specimens were counted by immunohistochemistry (IHC), and the analysis area was the invasive margin of metastatic lesions. Clinical data were collected retrospectively. Overall survival (OS) was calculated from the date of initial diagnosis to the date of last follow-up or death. Survival analyses were performed using the Kaplan-Meier method and log-rank test. Multivariate Cox regression was performed to asses impact of macrophages on OS.

RESULTS

The expression of CD206 could indicate the prognosis of patients with GCLM, and patients with high expression of CD206 had worse prognoses (P=0.0002). Univariate and multivariate analyses showed that CD206 was an independent risk factor for prognosis (HR 5.276, 95% CI: 1.730-16.089, P=0.003).

CONCLUSIONS

The CD206+ myeloid-derived tumor associated macrophages (TAMs) may predict whether patients could benefit from R1 resection of liver-metastatic lesions, which has important theoretical significance and practical value for accurately evaluating the clinical prognosis of patients with GCLM and guiding clinical treatment.

Definition of oligometastatic esophagogastric cancer and impact of local oligometastasis-directed treatment: A systematic review and meta-analysis

BACKGROUND

Local treatment (metastasectomy or stereotactic radiotherapy) for oligometastatic disease (OMD) in patients with esophagogastric cancer may improve overall survival (OS). The primary aim was to identify definitions of esophagogastric OMD. A secondary aim was to perform a meta-analysis of OS after local treatment versus systemic therapy alone for OMD.

METHODS

Studies and study protocols reporting on definitions or OS after local treatment for esophagogastric OMD were included. The primary outcome was the maximum number of organs/lesions considered OMD and the maximum number of lesions per organ (i.e. 'organ-specific' OMD burden). Agreement was considered to be either absent/poor (< 50%), fair (50%-75%), or consensus (≥ 75%). The secondary outcome was the pooled adjusted hazard ratio (aHR) for OS after local treatment versus systemic therapy alone. The ROBINS tool was used for quality assessment.

RESULTS

A total of 97 studies, including 7 study protocols, and 2 prospective studies, were included. OMD was considered in 1 organ with ≤ 3 metastases (consensus). 'Organ-specific' OMD burden could involve bilobar ≤ 3 liver metastases, unilateral ≤ 2 lung metastases, 1 extra-regional lymph node station, ≤ 2 brain metastases, or bilateral adrenal gland metastases (consensus). Local treatment for OMD was associated with improved OS compared with systemic therapy alone based on 6 non-randomized studies (pooled aHR 0.47, 95% CI: 0.30-0.74) and for liver oligometastases based on 5 non-randomized studies (pooled aHR 0.39, 95% CI: 0.22-0.59). All studies scored serious risk of bias.

CONCLUSIONS

Current literature considers esophagogastric cancer spread limited to 1 organ with ≤ 3 metastases or 1 extra-regional lymph node station to be OMD. Local treatment for OMD appeared associated with improved OS compared with systemic therapy alone. Prospective randomized trials are warranted.

Proposal of new treatment algorithm for gastric cancer liver metastases: Up-front surgery or conversion surgery?

Hepatectomy for gastric cancer liver metastases (GCLM) has a 5-year survival rate of 9-42%; however, indications for hepatectomy remain unclear. Many researchers have reported prognostic factors for GCLM after hepatectomy, but surgical indications vary according to the literature. Furthermore, the indication for optimal candidates for neoadjuvant chemotherapy and intensive chemotherapy is also unclear. To understand the indications for surgery and chemotherapy intended for hepatectomy for GCLM, a new treatment algorithm was created based on previously reported evidence from the viewpoint of hepatic surgeons.

Tumor metastasis: Mechanistic insights and therapeutic interventions

Cancer metastasis is responsible for the vast majority of cancer-related deaths worldwide. In contrast to numerous discoveries that reveal the detailed mechanisms leading to the formation of the primary tumor, the biological underpinnings of the metastatic disease remain poorly understood. Cancer metastasis is a complex process in which cancer cells escape from the primary tumor, settle, and grow at other parts of the body. Epithelial-mesenchymal transition and anoikis resistance of tumor cells are the main forces to promote metastasis, and multiple components in the tumor microenvironment and their complicated crosstalk with cancer cells are closely involved in distant metastasis. In addition to the three cornerstones of tumor treatment, surgery, chemotherapy, and radiotherapy, novel treatment approaches including targeted therapy and immunotherapy have been established in patients with metastatic cancer. Although the cancer survival rate has been greatly improved over the years, it is still far from satisfactory. In this review, we provided an overview of the metastasis process, summarized the cellular and molecular mechanisms involved in the dissemination and distant metastasis of cancer cells, and reviewed the important advances in interventions for cancer metastasis.

Identifying Optimal Surgical Intervention-Based Chemotherapy for Gastric Cancer Patients With Liver Metastases

BACKGROUND

This study aimed at evaluating the effects of surgical treatments-based chemotherapy in the treatment of gastric cancer with liver metastases (GCLM). It has not been established whether Liver-directed treatment (LDT) options such as hepatectomy and gastrectomy plus chemotherapy (HGCT), radiofrequency ablation and gastrectomy plus chemotherapy (RFAG), transarterial chemoembolization and gastrectomy plus chemotherapy (TACEG), gastrectomy plus chemotherapy (GCT) enhance the survival of GCLM patients.

METHODS

We performed systematic literature searches in PubMed, EMBASE, and Cochrane library from inception to September 2021. We created a network plot to comprehensively analyze the direct and indirect evidence, based on a frequentist method. A contribution plot was used to determine inconsistencies, a forest plot was used to evaluate therapeutic effects, the publication bias was controlled by funnel plot, while the value of surface under the cumulative ranking curves (SUCRA) was calculated to estimate rank probability.

RESULTS

A total of 23 retrospective studies were identified, involving 5472 GCLM patients. For OS and 1-, 2-, 3-year survival rate of all trials, meta-analysis of the direct comparisons showed significant better for HGCT treatments compared with GCT or PCT. In the comparison of the 5 treatments for 1-, 2-, 3-year survival rate, HGCT and RFAG were found to be more effective than GCT and PCT, respectively. By OS and 2-, 3-year survival rate analysis, RFAG was identified as the best option, followed by HGCT, TACEG, GCT and PCT. By 1-year survival rate analysis, HGCT and RFAG were identified as the most effective options.

CONCLUSION

HGCT and RFAG has remarkable survival benefits for GCLM patients when compared to TACEG, GCT and PCT. HGCT was found to exhibit superior therapeutic effects for GCLM patients for 1-year survival rate while RFAG was found to be a prospective therapeutic alternative for OS and 2-, 3-year survival rate.

SYSTEMATIC REVIEW REGISTRATION

identifier [10.37766/inplasy2020.12.0009].

Combined ablation-chemotherapy versus chemotherapy alone for pancreatic cancer with liver metastasis: a propensity score matching study

Objectives: To retrospectively assess the efficacy of combined ablation-chemotherapy in comparison to that of chemotherapy alone in patients with liver metastasized pancreatic ductal adenocarcinoma (lmPDAC).Methods: In total 104 patients with hepatic oligo metastasized PDAC were identified; among them, 74 patients underwent combined thermal ablation-chemotherapy, and 30 patients underwent chemotherapy alone. Through propensity score matching, 1:1 matching of the combined ablation-chemotherapy group and chemotherapy group was achieved. The primary endpoint of this study was overall survival (OS). Clinical and tumor-related factors affecting OS were also analyzed through univariate and multivariate analyses using the Cox risk model.Results: For patients treated with combined ablation-chemotherapy, the median OS was 10.77 months, while it was 5.77 months for patients treated with chemotherapy alone (P = 0.011). The survival benefit for patients treated with combined ablation-chemotherapy was still preserved in the matched cohort, with a median OS of 8.17 months compared to 5.77 months in the chemotherapy group. Univariate and multivariate analyses in the matched population also showed treatment with combined ablation-chemotherapy was an independent prognostic factor (P < 0.05).Conclusions: For patients with liver metastases from pancreatic cancer, the combined use of thermal ablation and systemic chemotherapy offers a chance for a better survival outcome.

The Chinese Society of Clinical Oncology (CSCO): Clinical guidelines for the diagnosis and treatment of gastric cancer, 2021

There exist differences in the epidemiological characteristics, clinicopathological features, tumor biological characteristics, treatment patterns, and drug selections between gastric cancer patients from the Eastern and Western countries. The Chinese Society of Clinical Oncology (CSCO) has organized a panel of senior experts specializing in all sub-specialties of gastric cancer to compile a clinical guideline for the diagnosis and treatment of gastric cancer since 2016 and renews it annually. Taking into account regional differences, giving full consideration to the accessibility of diagnosis and treatment resources, these experts have conducted expert consensus judgment on relevant evidence and made various grades of recommendations for the clinical diagnosis and treatment of gastric cancer to reflect the value of cancer treatment and meeting health economic indexes in China. The 2021 CSCO Clinical Practice Guidelines for Gastric Cancer covers the diagnosis, treatment, follow-up, and screening of gastric cancer. Based on the 2020 version of the CSCO Chinese Gastric Cancer guidelines, this updated guideline integrates the results of major clinical studies from China and overseas for the past year, focused on the inclusion of research data from the Chinese population for more personalized and clinically relevant recommendations. For the comprehensive treatment of non-metastatic gastric cancer, attentions were paid to neoadjuvant treatment. The value of perioperative chemotherapy is gradually becoming clearer and its recommendation level has been updated. For the comprehensive treatment of metastatic gastric cancer, recommendations for immunotherapy were included, and immune checkpoint inhibitors from third-line to the first-line of treatment for different patient groups with detailed notes are provided.

HIFU for the treatment of gastric cancer with liver metastases with unsuitable indications for hepatectomy and radiofrequency ablation: a prospective and propensity score-matched study

Background

The purpose of this study was to explore the efficacy and safety of high intensity focused ultrasound (HIFU) in gastric cancer with liver metastasis (GCLM) patients who were contraindicated for either hepatectomy or radiofrequency ablation (RFA).

Methods

This is a prospective, observational study on GCLM patients with 1–3 liver metastases. The primary gastric lesions were thoroughly resected and any case that exhibited extra-hepatic metastasis was excluded. A 1:2:2 propensity score-matching analysis was performed using a logistic regression model on the HIFU group, best supportive care (BSC) group, and palliative chemotherapy (PC) group. The primary endpoints include progression-free survival (PFS) and overall survival (OS).

Results

Forty patients were finally included, there were 8 cases in HIFU group, 16 cases in BSC group, and 16 cases in PC group. The median follow-up time for the entire cohort was 10 months. The median PFS was 16.5 months in HIFU group, 2 months in BSC group, and 5 months in PC group. The median OS was 27.5 months in the HIFU group, 7 months in the BSC group, and 11.5 months in the PC group. Additionally, no grade 3 or higher adverse events occurred in the HIFU group.

Conclusion

The results of this study showed that HIFU treatment could improve the long-term prognosis of GCLM patients without a significant increase in the occurrence of adverse events. Compared with PC and BSC, HIFU is the preferred treatment option when GCLM patients without extra-hepatic metastasis are unable to undergo either surgery or RFA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01307-y.

Surgical treatment of gastric cancer liver metastases: Systematic review and meta-analysis of long-term outcomes and prognostic factors

The prognosis of patients with metastatic gastric cancer remains dismal, with palliative treatment as standard of care. However, encouraging results have been reported for surgical resection of liver only metastatic gastric cancer in carefully selected patients. A systematic review of articles published from 2000 onwards was conducted according to PRISMA guidelines. Twenty-nine studies were included in qualitative and quantitative analysis. Meta-analysis of proportions pointed out 29.1 % 5ySR (I 2 = 39 %). The pooled weighted median of MSTs was 31.1 months. T stage > 2, metastasis greatest dimension ≥ 5 cm, the presence of multiple metastases and bilobar disease resulted among the strongest predictors of mortality. Funnel plots, Egger's tests, and P-curve analyses failed to show significant publication bias. Based on strict selection criteria and robust statistical analyses, our results show that, in very carefully selected patients without extrahepatic disease, surgical resection with curative intent may significantly improve overall survival.

Radiofrequency ablation versus traditional liver resection and chemotherapy for liver metastases from gastric cancer

Objective

To compare the short- and long-term outcomes of radiofrequency ablation (RFA) versus liver resection and chemotherapy for liver metastases from gastric cancer.

Methods

We retrospectively evaluated 50 patients who underwent curative gastrectomy and local treatments for liver metastases (RFA, n = 20; liver resection, n = 20; and chemotherapy, n = 10) from 2008 to 2018.

Results

The short- and long-term outcomes of each local treatment were evaluated. The median overall survival (OS) after RFA was similar to that after liver resection (20 vs. 20 months, respectively) and longer than that after chemotherapy (20 vs. 10 months, respectively). The 3-year OS and progression-free survival (PFS) rates after RFA were 20% and 10%, respectively, while those in the liver resection group were 23.5% and 23.5%, respectively. The 3-year OS rate after chemotherapy was 10%. The size and number of metastases were prognostic factors for patients with gastric cancer with liver metastasis without statistical significance.

Conclusions

Among patients with liver metastasis from gastric cancer, OS and PFS were satisfactory and comparable between RFA and liver resection but better than those of chemotherapy. RFA is an appropriate option for patients with gastric cancer who have a solitary liver metastasis measuring ≤3.0 cm.

Efficacy of Surgery for the Treatment of Gastric Cancer Liver Metastases: A Systematic Review of the Literature and Meta-Analysis of Prognostic Factors

BACKGROUND

In the last 10 years, the management of patients with gastric cancer liver metastases (GCLM) has changed from chemotherapy alone, towards a multidisciplinary treatment with liver surgery playing a leading role. The aim of this systematic review and meta-analysis is to assess the efficacy of hepatectomy for GCLM and to analyze the impact of related prognostic factors on long-term outcomes.

METHODS

The databases PubMed (Medline), EMBASE, and Google Scholar were searched for relevant articles from January 2010 to September 2020. We included prospective and retrospective studies that reported the outcomes after hepatectomy for GCLM. A systematic review of the literature and meta-analysis of prognostic factors was performed.

RESULTS

We included 40 studies, including 1573 participants who underwent hepatic resection for GCLM. Post-operative morbidity and 30-day mortality rates were 24.7% and 1.6%, respectively. One-year, 3-years, and 5-years overall survival (OS) were 72%, 37%, and 26%, respectively. The 1-year, 3-years, and 5-years disease-free survival (DFS) were 44%, 24%, and 22%, respectively. Well-moderately differentiated tumors, pT1-2 and pN0-1 adenocarcinoma, R0 resection, the presence of solitary metastasis, unilobar metastases, metachronous metastasis, and chemotherapy were all strongly positively associated to better OS and DFS.

CONCLUSION

In the present study, we demonstrated that hepatectomy for GCLM is feasible and provides benefits in terms of long-term survival. Identification of patient subgroups that could benefit from surgical treatment is mandatory in a multidisciplinary setting.

Current status of conversion surgery for stage IV gastric cancer

Palliative chemotherapy with best supportive care is a mainstay for patients with gastric cancer (GC) and distant metastasis. However, with advances in GC chemotherapy, multimodal treatment, including perioperative chemotherapy plus conversion surgery, has attracted attention as a new strategy to improve the outcome of patients with stage IV disease. Conversion surgery is defined as surgical treatment aimed at R0 resection after a good response to induction chemotherapy for tumors originally considered unresectable or marginally resectable for technical and/or oncological reasons. Various biological characteristics differ, depending on each metastatic condition in stage IV GC. The main metastatic pathways of GC can be divided into three categories: lymphatic, hematogenous, and peritoneal. In each category, considerable historical data on conversion surgery have demonstrated the benefits of individualized approaches. However, owing to the diversity of these conditions, a common definition, including the choice of induction chemotherapy, optimal timing of resection, and eligibility for conversion surgery, has not been established among surgical oncologists. Thus, we explore the current and future treatment options by reviewing the literature on this controversial topic comprehensively.

Clinical practice guidelines for the management of liver metastases from extrahepatic primary cancers 2021

BACKGROUND

Hepatectomy is standard treatment for colorectal liver metastases; however, it is unclear whether liver metastases from other primary cancers should be resected or not. The Japanese Society of Hepato-Biliary-Pancreatic Surgery therefore created clinical practice guidelines for the management of metastatic liver tumors.

METHODS

Eight primary diseases were selected based on the number of hepatectomies performed for each malignancy per year. Clinical questions were structured in the population, intervention, comparison, and outcomes (PICO) format. Systematic reviews were performed, and the strength of recommendations and the level of quality of evidence for each clinical question were discussed and determined. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations.

RESULTS

The eight primary sites were grouped into five categories based on suggested indications for hepatectomy and consensus of the guidelines committee. Fourteen clinical questions were devised, covering five topics: (1) diagnosis, (2) operative treatment, (3) ablation therapy, (4) the eight primary diseases, and (5) systemic therapies. The grade of recommendation was strong for one clinical question and weak for the other 13 clinical questions. The quality of the evidence was moderate for two questions, low for 10, and very low for two. A flowchart was made to summarize the outcomes of the guidelines for the indications of hepatectomy and systemic therapy.

CONCLUSIONS

These guidelines were developed to provide useful information based on evidence in the published literature for the clinical management of liver metastases, and they could be helpful for conducting future clinical trials to provide higher-quality evidence.

Debate: Improvements in Systemic Therapies for Liver Metastases Will Increase the Role of Locoregional Treatments

The benefit of resection of liver metastases depends on primary diseases. Neuroendocrine tumors are associated with favorable prognosis after resection of liver metastases. Gastric cancer has worse tumor biology, and resection of gastric liver metastases should be performed in selected patients. A multidisciplinary approach is well established for colorectal liver metastases (CLMs). Resection remains the only curative treatment of CLM. Chemotherapy and molecular-targeted therapy have improved survival in unresectable metastatic colorectal cancer. Understanding of the following two strategies, conversion therapy and two-stage hepatectomy, are important to make this patient group to be candidates for curative-intent surgery.

Is There a Role for Locoregional Therapies for Non-colorectal Gastrointestinal Malignancies?

The liver is the most common site of metastases from solid gastrointestinal tract tumors. Over the past few decades, the role of locoregional therapies, resection and thermal ablation, for neuroendocrine and colorectal liver metastases has been widely studied. However, for liver metastases originating from other gastrointestinal organs, the role of locoregional treatment remains unclear. This review summarizes and discusses the available evidence regarding benefits, risks, and indications for locoregional therapies for non-colorectal and non-neuroendocrine gastrointestinal liver metastases, highlighting the importance of multidisciplinary approach and patient selection.

The effectiveness of proton beam therapy for liver metastatic recurrence in gastric cancer patients

OBJECTIVE

The purpose of this cross-sectional study was to evaluate the efficacy and safety of proton beam therapy for liver metastatic recurrence in gastric cancer patients.

METHODS

Consecutive patients who underwent proton beam therapy from 2010 to 2015 were isolated from our institutional database. Patients with extrahepatic metastatic lesions were excluded. Seven patients were enrolled. The median diameter of target lesions was 31 mm (13-68 mm). The most frequent dosage was 72.6 Gy equivalent in 22 fractions. The effectiveness was assessed based on the local control, overall survival and progression-free survival rates. The local control, overall survival and progression-free survival rates were calculated using the Kaplan-Meier method. Adverse events were described according to the patients' medical records.

RESULTS

The median follow-up period was 41.7 months (20.7-66.3 months). The 3-year local control, overall survival and progression-free survival rates were 85.7, 68.6 and 43%, respectively. All patients completed proton beam therapy without interruption. No grade ≥3 adverse events were observed.

CONCLUSIONS

Proton beam therapy might be a treatment option for patients with liver metastasis of gastric cancer.

Is there a role for treatment-oriented surgery in liver metastases from gastric cancer?

BACKGROUND

Distant metastases are found in approximately 35% of patients with gastric cancer at their first clinical observation, and of these, 4%-14% involves the liver. Unfortunately, only 0.4%-2.3% of patients with metastatic gastric cancer are eligible for radical surgery. Although surgical resection for gastric cancer metastases is still debated, there have been changes in recent years, although several clinical issues remain to be defined and that must be taken into account before surgery is proposed.

AIM

To analyze the clinicopathological factors related to primary gastric tumor and metastases that impact the survival of patients with liver metastatic gastric cancer.

METHODS

We performed a systematic review of the literature from 2000 to 2018 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The study protocol was based on identifying studies with clearly defined purpose, eligibility criteria, methodological analysis, and patient outcome.

RESULTS

We selected 47 studies pertaining to the purpose of the review, which involved a total of 2304 patients. Median survival was 7-52.3 mo, median disease-free survival was 4.7-18 mo. The 1-, 2-, 3-, and 5-year overall survival (OS) was 33%-90.1%, 10%-60%, 6%-70.4%, and 0%-40.1%, respectively. Only five papers reported the 10-year OS, which was 5.5%–31.5%. The general recurrence rate was between 55.5% and 96%, and that for hepatic recurrence was between 15% and 94%.

CONCLUSION

Serous infiltration and lymph node involvement of the primary cancer indicate an unfavorable prognosis, while the presence of single metastasis or ≤ 3 metastases associated with a size of < 5 cm may be considered data that do not contraindicate liver resection.

The efficacy of clinical pathway in gastric cancer surgery

OBJECTIVES

Clinical pathways are useful tools for surgical quality improvement and better peri-operative clinical outcomes for patients undergoing major surgery. This study aimed to evaluate the influence of clinical pathway on early postoperative outcomes for gastric cancer patients.

MATERIAL AND METHODS

The study was designed as a retrospective cohort observational study. Patients who had undergone curative gastrectomy for gastric cancer were evaluated by using the gastric cancer database, which was prospectively maintained. The patients were divided into two groups based on the date when the clinical pathway was first used: The control group (May 2015-May 2016) and the clinical pathway group (June 2016-December 2017). Early postoperative outcomes including the length of hospital stay, start of the day of diet, and 30-day complications including reoperation, and operative mortality were compared after propensity score matching.

RESULTS

A total of 101 patients were analyzed, and the data of 70 patients (35 patients in each group) were compared after matching. Clinical pathway group demonstrated shorter hospital stay, earlier nasogastric tube removal, and start of earlier liquid/soft diet. Overall complication rate was lower in the clinical pathway group, while there was no statistically significant difference in major complication rates. No statistically significant difference was observed between the groups in terms of reoperation and operative mortality.

CONCLUSION

Clinical pathway may shorten the postoperative length of hospital stay and reduce the overall complication rate without increasing major morbidity in patients undergoing elective gastric cancer surgery.

Chinese consensus on the diagnosis and treatment of gastric cancer with liver metastases

Background

The incidence of gastric cancer with liver metastases (GCLM) is 9.9-18.7%, with a median survival time of 11 months and a 5-year survival rate <20%. Multidisciplinary treatment (MDT) is gradually gaining recognition as the most important method. However, specific treatment plans remain unclear. The aim of study was to provide a consensus to improve the diagnosis and treatment of GCLM.

Methods

We brought together experts from relevant medical fields across China, including the Chinese Research Hospital Association Digestive Tumor Committee, Chinese Association of Upper Gastrointestinal Surgeons, Chinese Gastric Cancer Association, and the Gastrointestinal Surgical Group of Chinese Surgical Society Affiliated to Chinese Medical Association, to discuss and formulate this consensus.

Results

A consensus was reached on the diagnosis and treatment of GCLM. Moreover, we have developed a new clinical classification system, the Chinese Type for Gastric Cancer Liver Metastases, based on the likelihood of a surgical treatment being successful.

Conclusions

The MDT mode should be implemented throughout all treatment of GCLM.A Chinese version of this expert consensus has been published in the Chinese Journal of Practical Surgery (Volume 39, Issue 10, p. 405-411). Written permission was obtained from the Chinese Journal of Practical Surgery to disseminate the expert consensus in English.

Treatment of metastatic gastric adenocarcinoma with image-guided high-dose rate, interstitial brachytherapy as second-line or salvage therapy

PURPOSE

We aimed to evaluate the safety and effectiveness of image-guided high-dose rate interstitial brachytherapy (iBT) for the treatment of patients with hepatic, lymphatic, and pancreatic metastases originating from gastric cancer, an entity rarely surgically treatable with curative intent.

METHODS

Twelve patients with a cumulative number of 36 metastases (29 liver, 2 pancreatic, 5 lymph node) from histologically proven gastric adenocarcinoma received iBT between 2010 and 2016 and were retrospectively analyzed. Every patient underwent palliative chemotherapy prior to iBT. The iBT procedure employs a temporarily, intratumorally placed iridium-192 source in a single fraction with the goal of tumor cell eradication. Effectiveness was assessed clinically and by radiologic imaging every three months.

RESULTS

Local tumor control was achieved in 32 of all treated metastases (89%). Four lesions showed a local recurrence after 7 months. Lesion sizes varied from 9 to 102 mm with a median of 20 mm. The median progression-free survival was 6.6 months (range, 1.8-46.8 months). The median overall survival was 11.4 months (range, 5-47 months). One patient suffered a major complication following iBT, hepatic hematoma and abscess (Common Terminology Criteria for Adverse Events grade 3), successfully dealt with by transcutaneous drainage.

CONCLUSION

iBT is an overall safe procedure, which facilitates high rates of local tumor control in treatment of metastatic gastric adenocarcinoma. Compared with surgical metastasectomy, similar overall survival rates could be achieved in our patient collective after iBT application.

Intestinal-type histology is associated with better prognosis in patients undergoing liver resection for gastric/esophagogastric-junction liver metastasis

The indication for resection of gastric/esophagogastric-junction liver metastasis (GELM) has yet to be established. This study aimed to investigate prognostic factors in patients undergoing GELM resection. From 2001 to 2015, 31 consecutive patients underwent resection for GELM; and factors for poor prognosis were evaluated. Of the 31 patients, 23 (74.2%) developed multiple liver metastases. The histology of gastric cancer was intestinal-type adenocarcinoma in 21 patients (67.7%). Median overall survival (OS) was 3.2 years. The 1-, 3-, and 5-year OS rates were 92.8%, 56.2%, and 42.2%, respectively. The 1-, 3-, and 5-year recurrence-free survival (RFS) rates were 58.5%, 31.3%, and 31.3%, respectively. Multivariate analysis indicated that intestinal-type adenocarcinoma was associated with a significantly lower risk of OS (hazard ratio [HR], 0.26; p =0.022) and RFS (HR, 0.25; p = 0.008). In multiple logistic regression analysis, intestinal-type adenocarcinoma (odds ratio, 0.14; p = 0.012) reduced incidence of extra-hepatic recurrence after GELM resection. In conclusion, GELM resection in patients with intestinal-type histology is preferable because intestinal-type adenocarcinoma is associated with better prognosis and a lower incidence of extra-hepatic recurrence than diffuse/other-type adenocarcinoma.

Surgery Strategies for Gastric Cancer With Liver Metastasis

Gastric cancer with liver metastasis is defined as advanced gastric cancer and remains one of the deadliest diseases with poor prognosis. Approximately 4–14% of patients with gastric cancers presented with liver metastases at the initial diagnosis. Owing to its incurability, first-line treatment for gastric cancer with liver metastases is systematic chemotherapy, whereas surgery is usually performed to alleviate severe gastrointestinal symptoms. However, continuously emerging retrospective studies confirmed the role of surgery in gastric cancer with liver metastases and showed significantly improved survival rate in patients assigned to a group of surgery with or without chemotherapy. Therefore, more and more convincing data that resulted from prospective randomized clinical trials is in need to clarify the surgery strategies in patients with gastric cancer with liver metastasis.

Conversion Surgery for Stage IV Gastric Cancer

The prognosis of stage IV gastric cancer (GC) is poor, with palliative chemotherapy remaining the main therapeutic option. Studies increasingly indicate that patients with unresectable stage IV GC, who undergo gastrectomy with radical intention after responding to several regimens of combined chemotherapy, can achieve good survival outcomes. Thus, surgery aiming at radical resection for unresectable stage IV GC after combined chemotherapy has received increasing attention in recent years. This novel therapeutic strategy was defined as conversion surgery in patients with unresectable stage IV GC and it can associate with significant improved survival when R0 resection can be achieved. Despite the recent advances in conversion surgery for patients with unresectable stage IV GC, selection criteria for combination chemotherapy regimens, indications for conversion surgery, optimal timing to surgery, and postoperative chemotherapy all remain controversial. This article reviews the current state of conversion surgery for unresectable stage IV GC.

Percutaneous stereotactic image-guided microwave ablation for malignant liver lesions

Thermal ablation has proven beneficial for hepatocellular carcinoma and possibly for colorectal liver metastases, but data is lacking for other liver metastases. Computer-assisted navigation can increase ablation efficacy and broaden its indications. We present our experience with percutaneous stereotactic image-guided microwave ablation (SMWA) for non-colorectal liver metastases (NCRLM), in form of a retrospective study including all SMWA for NCRLM from 2015 to 2017. Indication for SMWA was determined at a multidisciplinary tumorboard. End-points include recurrence, overall and liver-specific disease progression and complications. Twenty-three patients underwent 25 interventions for 40 lesions, including 17 neuroendocrine tumor, nine breast cancer, four sarcoma, two non-small cell lung cancer, three duodenal adenocarcinoma, one esophageal adenocarcinoma, one pancreatic adenocarcinoma, one ampullary carcinoma, one prostate carcinoma, and one renal cell carcinoma metastases. Median follow-up was 15 months (2-32). Incomplete ablation rate was 2.5% (1/40), local recurrence rate 10% (4/40). Three patients (12%) had minor complications. Overall disease progression was 73.9% (17/23), median disease-free survival 7 months (0-26) and overall survival 18 months (2-39). SIMWA is feasible, safe and minimally invasive for NCRLM in selected patients. While it might offer an alternative to resection or palliative strategies, the oncological benefit needs to be evaluated in a larger patient cohort.

Surgical management of metastatic gastric cancer: moving beyond the guidelines

Despite decreasing incidence, gastric cancer remains a major health problem worldwide and is associated with poor survival. The poor survival is mainly attributed to delayed presentation which may cause local or systemic metastases. The standard of care for patients with metastatic gastric cancer (MGC) is palliative chemotherapy with best supportive care. Although the survival has improved owing to advances in chemotherapeutic agents, it is still unsatisfactory, and some perspective changes are needed in the management of MGC to improve the outcomes. Therefore, various alternative treatment strategies for MGC have formed the most important research topics. Liver-directed treatment (LDT) options such as liver resection, radiofrequency ablation (RFA), microwave ablation (MWA), and hepatic artery infusion chemotherapy (HAIC) have been studied in the management of liver metastasis from gastric cancer (LMGC). Intraperitoneal chemotherapy (IPC) in addition to cytoreductive surgery (CRS) aiming to remove all macroscopic tumor focus resulting from peritoneal dissemination is the treatment option for peritoneal metastasis, while para-aortic lymph node dissection is the treatment option for para-aortic lymph node metastasis which is considered to be M1 disease. Conversion surgery is a novel concept aiming at R0 resection for originally unresectable or marginally resectable tumors after a remarkably good response to the chemotherapy. Large amounts of data in the literature have demonstrated the benefits of individualized approaches such as the combination of systemic and local treatment options in selected patient groups. In this review, we aimed to explore the current and future treatment options by reviewing the literature on this controversial topic.

Long-term survival of an elderly patient with advanced gastric cancer after combination therapy: a case report and literature review

Background

Gastric cancer ranks the fifth most common cancer, and the third leading cause of cancer-related deaths worldwide. Gastric cancer with liver metastasis (GCLM) has devastating prognosis, however, optimal treatment of GCLM, especially in elderly patients, has yet to be clarified.

Case presentation

A 75-year-old man was diagnosed with advanced gastric cancer (GC), presenting with acute gastrointestinal bleeding and synchronous metastatic lesion in liver. Based on multidisciplinary team (MDT)‘s decision, this patient underwent distal palliative gastrectomy with R1 margin. Histopathological diagnosis was stage IV gastric adenocarcinoma (pT3N2M1), HER2 negative. The patient was treated with chemotherapy and argon-helium cryoablation of liver and lung metastases.HER-2 gene amplification was identified in peripheral blood at later stage of therapy. The patient had been followed-up for 39 months, in sharp contrast to a median survival time of 13.8 months for majority of advanced GC.

Conclusions

Palliative distal gastrectomy in combination with chemotherapy and cryoablation significantly prolongs overall survival of an elderly patient with GCLM.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5683-4) contains supplementary material, which is available to authorized users.

[Therapeutic approach in oligometastatic gastric and esophageal cancer]

The therapeutic approach to patients with oligometastatic gastric cancer and esophageal cancer is currently undergoing a shift towards a more aggressive therapy including surgical resection. In the current German S3 guidelines surgical treatment of metastatic disease is not recommended; however, nowadays interdisciplinary tumor boards have to evaluate such patients increasingly more often. On an individual basis a radical surgical resection of the primary tumor and the metastases is considered and performed in patients who respond well to multimodal chemotherapy concepts. In this review article the currently available data from the literature are discussed and a foundation for individually extended surgical approaches is presented. Together with the currently available results of the FLOT 3 study and the mostly retrospective studies, it seems to be possible to identify patients who would profit from such an aggressive treatment. In the future randomized prospective studies, such as the RENAISSANCE/FLOT 5 study and the GASTRIPEC study will have to evaluate whether an aggressive surgical therapy within multimodal therapy concepts of metastatic gastric and esophageal carcinomas is warranted.

Aggressive Graphic/Surgical R0 Resection and Jejunal Interposition with Preservation of Mesojejunal Autonomic Nerves in Patients with Stage IV Esophagogastric Junction Adenocarcinoma: A Report of 3 Cases

BACKGROUND Three patients with stage IV esophagogastric junction cancer (EGJC) underwent extended resection to achieve a graphic/surgical R0 status (no visible remnant of viable tumor in imaging/surgical findings) and adjuvant chemotherapy from the early postoperative period. We also introduced use of our digestive reconstruction technique in these patients. CASE REPORT We used jejunal interposition for digestive reconstruction, which involved end-to-end jejunojejunostomy with a biofragmentable anastomosis ring. The mesojejunal autonomic nerves of the lifted jejunum were preserved. The first adenocarcinoma involved the perilesional lymph nodes (LNs). Graphic/surgical R0 resection was completed by para-aortic LN dissection. The diagnosis (Japanese Classification of Gastric Carcinoma) was stage IV [pM1(LYM)]. Adjuvant chemotherapy began on postoperative day (POD) 11. The second adenocarcinoma was accompanied by a solitary lung metastasis. Intraoperative cytology of ascitic fluid was positive, and cisplatin was intraperitoneally administered. Adjuvant chemotherapy began on POD 10. The solitary lung metastasis was then resected, and graphic/surgical R0 resection was achieved. The diagnosis was stage IV [pM1(PUL) and CY1]. The third adenocarcinoma was accompanied by multiple liver metastases and metastatic regional LNs. The diagnosis was stage IV [H1]. Systemic chemotherapy was repeated. Only a solitary liver metastasis remained and was treated by radiofrequency ablation. Conversion surgery was conducted, achieving graphic/surgical R0 resection. Systemic chemotherapy was continued from POD 10. CONCLUSIONS For patients with stage IV EGJC, extended resection to achieve a graphic/surgical R0 status is still controversial, and systemic chemotherapy is important. The results of the present study suggest that our physiological reconstruction technique does not affect the efficacy of other therapies, such as adjuvant chemotherapy.

Influence of thermal ablation of hepatic metastases from gastric adenocarcinoma on long-term survival: Systematic review and pooled analysis

The objectives of this systematic review and pooled analysis were to examine long-term survival, morbidity, and mortality following thermal ablation of gastric cancer hepatic metastases and to identify prognostic factors that improve survival.Patients with hepatic metastases from gastric cancer are traditionally treated with palliative chemotherapy. Surgical resection is an alternative treatment of hepatic metastases. Whether patients can obtain benefit from thermal ablation of hepatic metastases is still controversial.A systematic literature search was undertaken (1990-2018). Publications were included if they studied more than 7 patients undergoing thermal ablation for hepatic metastasis from gastric cancer in the absence of peritoneal disease or other distant organ involvement. The primary outcome was the hazard ratio (HR) for overall survival. Comparison between thermal ablation and systematic chemotherapy or hepatic resection had been carried out. The influence of liver metastasis-related factors, such as <3 cm versus >3 cm, single versus multiple and metachronous versus synchronous upon survival was also assessed.The median survival of thermal ablation for the 12 studies included was 22.93[20.45-25.41] months. Procedures were associated with a median 30-day morbidity of 6% (0%-23%) and with no mortality. The median 1-year, 2-year, 3-year, and 5-year survival were 79.14%, 39.79%, 28.45%, and 19.46%, respectively. Thermal ablation of hepatic metastasis was associated with improved overall survival compared with systematic chemotherapy (HR = 2.12; 95% CI 0.77-3.47; P=.000). Meta-analysis confirmed the additional survival benefit of size <3 cm (HR = 1.46; 95% CI 1.03-1.88; P = .002) and receiving chemotherapy after thermal ablation (HR = 2.14; 95% CI 1.05-3.23; P = .000).A use of RFA/ microwave ablation (MWA) as a liver-directed treatment may provide greater survival benefit than chemotherapy and is an alternative option for the treatment of liver-only metastases from gastric cancer. With the appropriate selection of patients, such as tumors <3 cm in diameter, thermal ablation may provide better prognosis than hepatic resection of hepatic metastasis with lower morbidity and mortality. Postoperation chemotherapy should be provided to patients with GLM who received thermal ablation.

Systemic chemotherapy in combination with liver-directed therapy improves survival in patients with pancreatic adenocarcinoma and synchronous liver metastases

OBJECTIVES

We investigated whether the combination of systemic chemotherapy (SCT) and liver-directed therapy (LDT) was superior to chemotherapy alone for patients with pancreatic adenocarcinoma and synchronous liver metastases (PACLM).

METHODS

We reviewed the medical records of 184 patients treated with SCT ± LDT at Tianjin Medical University Cancer Hospital from 2001 to 2015. Overall survival (OS) was the primary end-point. The role of treatment modality and other clinical factors was evaluated by univariate and Cox regression analyses.

RESULTS

Sixty-four (34.8%) patients in the SCT-LDT group and 120 (65.2%) patients in the SCT group were included in the analysis. Baseline clinical characteristics were similar between the groups (all P > 0.05). The median survival was 8.7 months in the SCT-LDT group and was 6.3 months in the SCT group. The 0.5-, 1-, 2- and 3-year survival rates were 67.2%, 33.4%, 13.3% and 8.9%, respectively, after SCT-LDT, and were 54.9%, 19.0%, 4.5% and 2.0%, respectively, after SCT (P = 0.01). Primary tumor size, ascites, and treatment modality (SCT + LDT vs. SCT) independently predicted survival (P < 0.05). The clinical efficacy congruously favored the SCT-LDT group across the majority of subgroups.

CONCLUSIONS

SCT combined with LDT was well tolerated and may be effective to improve survival of patients with PACLM. Ascites and large primary tumor size were poor prognostic factors associated with survival.

Long-term Survival after Repeated Local Therapy and Salvage Chemotherapy for Recurrent Metastases from Gastric Cancer: a Case Report and Literature Review

We report a rare case of long-term survival in a patient who received local therapy and salvage chemotherapy for recurrent metastases, along with a literature review. A 65-year-old male patient underwent subtotal gastrectomy for advanced gastric adenocarcinoma. Six months after gastrectomy, 2 metastatic intra-abdominal lymph node enlargements were detected, which were treated with radiotherapy. At 55 months after gastrectomy, an abdominal wall mass was detected, which was treated by surgical resection. The patient received 5-fluorouracil/leucovorin/irinotecan chemotherapy for 27 months before and after radiotherapy and docetaxel chemotherapy for 6 months after surgical resection of the abdominal wall metastasis. At the last visit, 7.8 years since the initial resection of the primary gastric cancer and 6.2 years since detection of the first metastases, the patient was disease-free and required no further chemotherapy. This case suggests that repeated local therapy offers potential for long-term survival in a carefully selected subset of patients with recurrent metastases.

Surgery with curative intent for stage IV gastric cancer: Is it a reality of illusion?

Gastric cancer with metastases outside of the regional lymph nodes is deemed oncologically unresectable. Nevertheless, some metastatic lesions are technically resectable by applying established surgical techniques such as para-aortic lymphadenectomy and hepatectomy. At the time of compilation of the Japanese gastric cancer treatment guidelines version 4, systematic reviews were conducted to see whether it is feasible to make any recommendation to dissect both the primary and metastatic lesions with intent to cure, possibly as part of multimodality treatment. Long-term survivors were found among carefully selected groups of patients both in prospective and retrospective studies. In addition, there is a growing list of publications reporting encouraging outcomes of gastrectomy conducted after exceptionally good response to chemotherapy, usually among patients who underwent R0 resection. This type of surgery is often referred to as conversion surgery. It is sometimes difficult to define a clear borderline between curative surgery scheduled after neoadjuvant chemotherapy and the conversion surgery. This review summarizes what we knew after the literature reviews conducted at the time of compiling the Japanese guidelines and in addition reflects some new findings obtained thereafter through clinical trials and retrospective studies. Metastases were divided into three categories based on the major metastatic pathways: lymphatic, hematogenous, and peritoneal. In each of these categories, there were findings that could provide hope for patients with metastatic disease. These findings implied that the surgical technique that we already use could become more useful upon further developments in antineoplastic agents and drug delivery.

Oncological outcomes after hepatic resection and/or surgical microwave ablation for liver metastasis from gastric cancer

BACKGROUND

Indications and efficacy of surgical treatment for liver metastases from gastric cancer (LMGCs) remain controversial. This retrospective study was designed to clarify the benefits of surgical treatment and identify prognostic factors.

METHODS

Between December 1997 and December 2015, 34 consecutive patients underwent hepatic resection and surgical microwave ablation for synchronous or metachronous LMGCs at our institution. We analyzed their cumulative overall survival (OS) and recurrence-free survival (RFS) rates and clinical parameters to identify predictors of prognosis.

RESULTS

Of the 34 patients, 14 underwent hepatic resection, 13 underwent surgical microwave ablation, and 7 underwent hepatic resection combined with surgical microwave ablation. Their OS rates were 1-year: 84.4%, 3-year: 38.6%, and 5-year: 34.7%; and their RFS rates were 1-year: 38.5%, 3-year: 28.0%, and 5-year: 28.0%. OS did not significantly vary among the surgical procedures. In multivariable analysis, positive of both CEA and CA19-9 were independent predictors of poor survival (hazard ratio [HR] 4.51; P = 0.049) and early recurrence (HR 5.70; P = 0.047).

CONCLUSIONS

Both hepatic resection and surgical microwave ablation for LMGCs are effective and can improve survival in selected patients.

Current management of liver metastases from gastric cancer: what is common practice? New challenge of EORTC and JCOG

The role of multidisciplinary treatment including surgery for liver metastases from gastric cancer (LMGC) is controversial. Studies to answer this clinical question are increasing in number, but all published data thus far are based on retrospective analyses with limited sample sizes. Thus, the European Organisation for Research and Treatment of Cancer (EORTC) Gastrointestinal Tract Cancer Group (GITCG) and the Japan Clinical Oncology Group (JCOG) Stomach Cancer Study Group (SCSG) initiated a collaboration to develop an optimal treatment strategy for LMGC. Before planning a prospective study, a questionnaire was sent out to the network members of both groups in June 2016 to clarify current common practice in each region. Sixty-seven sites from 17 countries in the EORTC network and 55 sites from Japan responded. According to the survey, for patients with resectable LMGC without extrahepatic metastases, preoperative chemotherapy followed by resection of both primary (if still in place) and liver lesions was the preferred option for both the synchronous and the metachronous setting. For patients with unresectable LMGC, most of the sites recommended chemotherapy only. In this article, the detailed results of this survey are reported, shedding light on current community practice, and a joint EORTC-JCOG strategy of investigation is delineated.

Proton beam therapy for liver metastases from gastric cancer

Liver metastases from gastric cancer (LMGC) is a non-curable, fatal disease with a 5-year survival rate of <10%. Although various local treatments have been applied, their clinical utility has not been established. The purpose of this study was to investigate the safety and effectiveness of proton beam therapy (PBT) for the treatment of patients with LMGC. A total of nine patients (seven men, two women; aged 56-78 years) with LMGC who received PBT between 2002 and 2012 were retrospectively reviewed. Patients who had tumors confined to the liver were investigated, and patients who had extrahepatic tumors were excluded. Six of the patients had solitary tumors, and three patients had multiple tumors. The total irradiation dose was 64-77 Gy relative biological effectiveness (RBE), and three patients received concurrent chemotherapy. The overall and progression-free survival (OS and PFS) rates, local control (LC) rate, and adverse effects were investigated. All patients completed treatment without interruption, and late adverse effects of higher than Grade 3 were not observed. The OS rates at 1, 3 and 5 years were 100%, 78% and 56%, respectively (median, 5.5 years); the PFS rates were 67%, 40% and 40% (median, 2.6 years); and the LC rates were 89%, 71% and 71%. PBT was demonstrated to be a safe treatment, and the OS and PFS rates were not inferior to those for other types of local treatment. Therefore, PBT should be considered as an effective local treatment option for patients with LMGC.

Recent trends of gastric cancer treatment in Turkey

Gastric cancer is the fifth most common type of cancer and is the fourth most common death due to cancer in Turkey. Incidence and mortality rates are one of the highest among European countries. Despite the high rates, management of gastric cancer is still an issue of debate in Turkey and national guidelines have yet to be established. While the treatment plan following the diagnosis of gastric cancer is determined by a multidisciplinary meeting at high-volume centers, the plan in the majority of cases in Turkey is decided based on the decision of an individual physician. The primary goal of the treatment strategy is to obtain the best oncological outcomes and quality of life within the acceptable treatment-related morbidity. Therefore, R0 resection is intended by using standardized surgery with an individualized approach, while avoiding surgery if a curative resection is not possible. In this review, presenting on the recent trends of gastric cancer treatment including surgical, endoscopic, adjuvant/neoadjuvant and conversion treatment options in Turkey are aimed by exploring the institutional approach.

Microwave ablation is effective against liver metastases from gastric adenocarcinoma

PURPOSE

The resection rate for liver metastases from gastric cancer is only 1.4-21.1%. This study aimed to evaluate the safety and therapeutic efficacy of microwave ablation (MWA) for liver metastases from gastric adenocarcinoma (LMGC).

MATERIALS AND METHODS

A database of 108 gastric adenocarcinoma patients with liver metastases who underwent MWA (n = 32) or systemic chemotherapy (n = 76) for LMGC between 2008 and 2016 was reviewed. Overall survival curves were assessed and compared based on different therapies.

RESULTS

All the patients were followed up for a median of 15 months (range, 2-68 months). The median cumulative survival times of patients after MWA and systemic chemotherapy were 25 (95% confidence interval (CI) 16.5-33.5) months and 12 (95% CI 7.7-16.3) months, respectively (HR 1.751, 95% CI 1.077-2.845; p = .015). The 1-, 3-, and 5- year survival rates were 80.9%, 31.2%, and 16.7% (MWA group); and 50.0%, 18.8%, and 5.4% (chemotherapy group), respectively. In the MWA group, side effects were reported in eight patients who developed abdominal pain, transient fever, or nausea. Dominant size, number of liver metastases, therapeutic modalities, and presence of extrahepatic metastases showed significant prognostic value in univariate analyses; while the latter three were identified as independent prognostic factors in multivariate regression analysis.

CONCLUSIONS

MWA is a safe and useful alternative for liver metastases from gastric adenocarcinoma in selected patients.

Treatment outcomes of hepatectomy for liver metastases of gastric cancer diagnosed using contrast-enhanced magnetic resonance imaging

BACKGROUND

Chemotherapy is the standard treatment for liver metastases of gastric cancer (LMGC). Hepatectomy for LMGC reportedly has a 5-year survival rate of 13-37 %; however, its significance has not been established. At our hospital, hepatectomy is performed for patients with three or fewer metastases diagnosed using contrast-enhanced magnetic resonance imaging (MRI). To identify the ideal patient subpopulation for resection, we retrospectively analyzed treatment outcomes in patients with LMGC who underwent hepatectomy.

METHODS

Clinicopathological factors affecting survival were explored using univariate and multivariate analyses in 28 patients who underwent hepatectomy for LMGC diagnosed using contrast-enhanced MRI between December 2004 and October 2014.

RESULTS

The study included 23 men and 5 women with a median age of 72 years. Metastases were synchronous in 15 patients and metachronous in 13 patients. The median overall survival time was 49 months, with a 5-year survival rate of 32 %. Univariate analysis revealed that overall survival time was shorter in the presence of the following factors: age ≥70 years (p = 0.030), synchronous liver metastases (p = 0.017), and presence of postoperative complications (p = 0.042). In patients with metachronous liver metastases, the post-resection 5-year survival rate was 59 %.

CONCLUSIONS

The 5-year survival rate was 32 % in patients who underwent hepatectomy for LMGC according to our criteria, suggesting that hepatectomy is an important treatment if indications are on the basis of contrast-enhanced MRI. Therefore, active resection should be considered, particularly for patients with metachronous liver metastases.

Microwave ablation of liver malignancies: comparison of effects and early outcomes of percutaneous and intraoperative approaches with different liver conditions : New advances in interventional oncology: state of the art

Liver thermal ablation is an alternative treatment for hepatocellular carcinoma (HCC) and secondary liver malignancies. Microwave ablation (MWA) produces large ablation zones (AZ) in short time; however, AZ prediction is based on preclinical ex vivo models, rising concerns about reproducibility and safety in humans. We aimed to investigate the effects produced by a new-generation MWA system on human liver in vivo with different approaches (percutaneous or intraoperative) and liver conditions (cirrhosis or previous chemotherapy treatment), in comparison with manufacturer-provided predictions based on ex vivo animal models. Complete tumor ablation (CA) and early clinical outcomes were also assessed. From October 2014, 60 consecutive patients (cirrhotic = 31; non-cirrhotic = 10; chemotherapy-treated = 19) with 81 liver nodules (HCC = 31; mets = 50) underwent MWA procedures (percutaneous = 30; laparotomic = 18; laparoscopic = 12), with a 2450 MHz/100 W generator with Thermosphere™ Technology (Emprint™, Medtronic). A contrast-enhanced CT or MR was performed after one month to assess CA and measure AZ. A linear correlation between AZ volumes and ablation times was observed in vivo, without differences from manufacturer-provided ex vivo predictions in all operative approaches and liver conditions. Other independent variables (sex, age, nodule location) showed no relationship when added to the model. Median (IQR) longitudinal and transverse roundness-indexes of the AZs were, respectively, 0.77(0.13) and 0.93(0.11). CA at 1 month was 93% for percutaneous and 100% for intraoperative procedures (p = 0.175). Thirty-day morbidity and mortality were 3% and 0%. MWA with Thermosphere™ Technology produces predictable AZs on human liver in vivo, according to manufacturer-provided ex vivo predictions. In our experience, this new-generation MWA system is effective and safe to treat liver malignancies in different operative and clinical settings.