The long-term survival of stage IV gastric cancer patients with conversion therapy

Deep learning progressive distill for predicting clinical response to conversion therapy from preoperative CT images of advanced gastric cancer patients

BACKGROUND AND OBJECTIVE

Identifying patients suitable for conversion therapy through early non-invasive screening is crucial for tailoring treatment in advanced gastric cancer (AGC). This study aimed to develop and validate a deep learning method, utilizing preoperative computed tomography (CT) images, to predict the response to conversion therapy in AGC patients. This retrospective study involved 140 patients. We utilized Progressive Distill (PD) methodology to construct a deep learning model for predicting clinical response to conversion therapy based on preoperative CT images. Patients in the training set (n = 112) and in the test set (n = 28) were sourced from The First Affiliated Hospital of Wenzhou Medical University between September 2017 and November 2023. Our PD models' performance was compared with baseline models and those utilizing Knowledge Distillation (KD), with evaluation metrics including accuracy, sensitivity, specificity, receiver operating characteristic curves, areas under the receiver operating characteristic curve (AUCs), and heat maps. The PD model exhibited the best performance, demonstrating robust discrimination of clinical response to conversion therapy with an AUC of 0.99 and accuracy of 99.11% in the training set, and 0.87 AUC and 85.71% accuracy in the test set. Sensitivity and specificity were 97.44% and 100% respectively in the training set, 85.71% and 85.71% each in the test set, suggesting absence of discernible bias. The deep learning model of PD method accurately predicts clinical response to conversion therapy in AGC patients. Further investigation is warranted to assess its clinical utility alongside clinicopathological parameters.

Comparison of outcomes between surgery and non-surgery after conversion therapy for advanced gastric cancer with unresectable factors: a systematic review and meta-analysis

BACKGROUND

Advanced gastric cancer (AGC) with unresectable factors presents a significant treatment challenge. Conventional treatments such as systemic chemotherapy, radiotherapy, and immunotherapy can delay disease progression but often yield limited outcomes. For stage III-IV gastric cancer with unresectable factors, conversion therapy based on chemotherapy can achieve tumor downstaging, providing a subset of patients with the opportunity for curative surgery. However, the efficacy of multimodal approaches combining chemotherapy, with or without immunotherapy, and conversion surgery compared to chemotherapy alone remains controversial.

METHODS

We conducted a systematic review and meta-analysis of high-quality studies published between January 2014 and November 2024, assessing the role of surgery following conversion therapy in advanced gastric cancer. Relevant studies were retrieved from PubMed, Embase, and Web of Science databases. All included studies were observational; no randomized trials were available. Clinical data, including overall survival (OS), progression-free survival (PFS), objective response rate (ORR) and adverse event (AE) rates, were analyzed using RevMan 5.4.

RESULTS

Twelve observational cohort studies were included. Conversion surgery(CS) was associated with improved 1-year, 3-year, and 5-year OS rates (RR 0.38, 95% CI: 0.31-0.47; RR 0.64, 95% CI: 0.54-0.76; RR 0.77, 95% CI: 0.65-0.91, respectively) and increased 1-year and 3-year PFS rates (RR 0.57, 95% CI: 0.49-0.99; RR 0.67, 95% CI: 0.57-0.78, respectively). No significant difference in AE rates was observed between groups.

CONCLUSIONS

Conversion surgery following chemotherapy in stage III-IV gastric cancer is associated with improved OS and PFS in observational studies. However, these findings may reflect inherent prognostic differences between groups, as surgery was only feasible for chemotherapy responders. Prospective trials are needed to validate causality.

Randomized controlled phase III study comparing chemotherapy alone versus conversion surgery after a remarkable response to chemotherapy in patients with initially unresectable cStage IVB or pStage IV gastric cancer (JCOG2301, Conversion study)

The standard approach for stage IV gastric cancer is palliative chemotherapy. However, despite the advancements in various chemotherapy regimens, the prognosis remains poor, highlighting the urgent need to develop more effective treatment strategies. The controversy persists regarding the integration of a local therapy including surgery in the management of unresectable stage IV gastric cancer. This randomized phase III trial aims to confirm the additional benefit of conversion surgery following palliative chemotherapy compared with palliative chemotherapy alone with respect to overall survival in patients initially diagnosed with unresectable clinical stage IVB or pathological stage IV gastric cancer after a remarkable response to chemotherapy. This study plans to enroll 126 patients from 63 institutions in Japan for 5 years, and it has been registered in the Japan Registry of Clinical Trials as jRCTs031240340 (https://jrct.niph.go.jp/latest-detail/jRCTs031240340).

Hyperthermic intraperitoneal chemotherapy plus SOX chemotherapy versus SOX chemotherapy alone in patients with gastric cancer and peritoneal metastasis: a phase II randomized clinical trial

Background

The prognosis of patients with gastric cancer with peritoneal metastasis (GCPM) is exceedingly poor. This study evaluated the efficacy and safety of hyperthermic intraperitoneal chemotherapy (HIPEC) with paclitaxel combined with S-1 and oxaliplatin (SOX) in the treatment of GCPM.

Methods

Patients with pathologically confirmed primary gastric adenocarcinoma and laparoscopy-confirmed peritoneal metastasis were enrolled and randomized to receive either HIPEC plus SOX (HIPEC group) or SOX alone (SOX group). The primary endpoint was progression-free survival (PFS), and the secondary endpoints were 1-year survival rate, overall survival (OS), and safety.

Results

Among the included patients, 30 were assigned to the HIPEC group and 29 to the SOX group. Compared to the HIPEC group, the SOX group had a significantly higher median PFS (SOX: median 8.5 months, IQR, 3.8-21.8 months; HIPEC: median 6.1 months, IQR, 3.3-10.8 months; P=0.004) and OS (SOX: median 13.0 months, IQR, 6.3-16.6 months; HIPEC: median 10.0 months, IQR, 5.2-24.0 months; P=0.02). The 1-year survival rate was 50.0% in the SOX group and 37.9% in HIPEC group, but the difference was not statistically significant. No serious adverse events related to the protocol treatment occurred in any patients.

Conclusions

This trial failed to show the superiority of HIPEC with SOX over SOX alone. Further research into this regimen is needed.

Trial Registration

ClinicalTrials.gov NCT03604614.

Immunological Analysis of Prognostic Factors in Conversion Surgery Cases for Gastric Cancer

INTRODUCTION

In order to clarify the optimal strategy regarding conversion surgery (CS) for gastric cancer (GC) patients, we focused on clinicopathological findings, including immunological factors, related to the favorable prognosis in patients with stage IV GC who underwent CS.

MATERIALS AND METHODS

A total of 25 patients with Stage IV GC who underwent induction chemotherapy (IC) and CS at our hospital between 2010 and 2021 were enrolled in this study. Biopsy specimens before IC and surgical specimens were collected. Immunohistochemical staining was performed using programmed death-ligand 1 (PD-L1) antibody, translationally controlled tumor protein (TCTP) antibody, and CD20 antibody. Prognostic factors were investigated using clinicopathological factors as well as immunological factors such as PD-L1, TCTP, and CD20 expression.

RESULTS

cN0, ycStage1-2, R0-1 surgery, D2 lymph node dissection, ypN0, and ypStage1-2 were significantly associated with favorable overall survival. Among patients who underwent R0/1 surgery, only histological type was a significant prognostic factor for recurrence-free survival. Low PD-L1 expression before IC and high TCTP expression after IC were significantly associated with favorable recurrence-free survival.

CONCLUSIONS

In addition to clinical factors, high TCTP expression after IC was identified as a significant favorable prognostic factor, which could help in identifying candidates for CS in the future.

Effectiveness of conversion surgery in stage IV gastric cancer

BACKGROUND

For patients with stage IV gastric cancer (GC), systemic therapy is often the standard treatment, but the prognosis remains poor. Conversion surgery (CS) has emerged as a potential therapeutic option for selected patients who had certain response to chemotherapy. This study aims to compare the survival outcomes of CS versus continued chemotherapy (CT) in stage IV GC.

METHODS

We conducted a retrospective cohort study of 52 patients with stage IV gastric adenocarcinoma, from January-2018 to June-2023. Patients were divided into two groups: those who underwent CS (CS group) after a response to chemotherapy and those who continued with systemic chemotherapy (CT group). Baseline characteristics, chemotherapy toxicity, surgical outcomes, and survival data were analyzed and compared.

RESULTS

Among 52 patients, 26 patients underwent CS, while other 26 continued with CT. The CS group showed a significantly higher 3-year overall survival (OS) rate and median survival time (MST) compared to the CT group (36 % vs. 15 %, HR = 0.39, 95%CI: 0.19-0.79, p = 0.009; 23.4 months vs. 14.7 months, p < 0.001, respectively). Subgroup analysis by Yoshida classification revealed superior survival outcomes for CS in category 3 (MST: 26.1 months vs. 12.6 months, p < 0.001). Multivariate analysis indicated that CS were associated with a longer survival. No major postoperative complications were observed in the CS group.

CONCLUSIONS

Conversion surgery improved survival outcomes in selected stage IV GC patients compared to systemic chemotherapy alone. CS should be considered as a treatment option for patients who responds to initial chemotherapy, particularly those in Yoshida category 3.

A prognostic nomogram to predict the cancer-specific survival of patients with initially diagnosed metastatic gastric cancer: a validation study in a Chinese cohort

BACKGROUND

Few studies have been designed to predict the survival of Chinese patients initially diagnosed with metastatic gastric cancer (mGC). Therefore, the objective of this study was to construct and validate a new nomogram model to predict cancer-specific survival (CSS) in Chinese patients.

METHODS

We collected 328 patients with mGC from Northern Jiangsu People's Hospital as the training cohort and 60 patients from Xinyuan County People's Hospital as the external validation cohort. Multivariate Cox regression was used to identify risk factors, and a nomogram was created to predict CSS. The predictive performance of the nomogram was evaluated using the consistency index (C-index), the calibration curve, and the decision curve analysis (DCA) in the training cohort and the validation cohort.

RESULTS

Multivariate Cox regression identified differentiation grade (P < 0.001), T-stage (P < 0.05), N-stage (P < 0.001), surgery (P < 0.05), and chemotherapy (P < 0.001) as independent predictors of CSS. Nomogram of chemotherapy regimens and cycles was also designed by us for the prediction of mGC. Thus, these factors are integrated into the nomogram model: the C-index value was 0.72 (95% CI 0.70-0.85) for the nomogram model and 0.82 (95% CI 0.79-0.89) and 0.73 (95% CI 0.70-0.86) for the internal and external validation cohorts, respectively. Calibration curves and DCA also demonstrated adequate fit and ideal net benefit in prediction and clinical applications.

CONCLUSIONS

We established a practical nomogram to predict CSS in Chinese patients initially diagnosed with mGC. Nomograms can be used to individualize survival predictions and guide clinicians in making therapeutic decisions.

Prognostic significance of osteosarcopenia in patients with stage IV gastric cancer undergoing conversion surgery

PURPOSE

Recently, several investigators have focused on the clinical significance of osteosarcopenia in malignancies; however, its prognostic impact on patients with gastric cancer after conversion surgery (CS) remains unclear. Therefore, we aimed to investigate sarcopenia, osteopenia, and osteosarcopenia in this patient population.

METHODS

We retrospectively analyzed 24 patients with gastric cancer who underwent CS. Before CS, the skeletal muscle index at the L3 vertebra and bone mineral density at the Th11 vertebra were measured to investigate sarcopenia and osteopenia, respectively. Osteosarcopenia was defined as the coexistence of sarcopenia and osteopenia. The relationship between perioperative osteosarcopenia and patient prognosis, including clinicopathological factors, was assessed.

RESULTS

Among the 24 patients, 10 (42%) had osteosarcopenia. Osteosarcopenia was significantly correlated with body mass index, depth of tumor invasion, and tumor stage (all p < 0.05). The median overall survival and disease-free survival after CS in patients with osteosarcopenia were significantly shorter than those in patients without osteosarcopenia (all p < 0.05). In the multivariate analysis, osteosarcopenia was identified as an independent factor related to overall survival alone (p = 0.04).

CONCLUSION

Assessment of osteosarcopenia has clinical utility in predicting the prognosis after CS in patients with stage IV gastric cancer after chemotherapy.

Conversion surgery for stage IV gastric cancer after third-line immunotherapy: a case report

The 5-year overall survival rate for stage IV gastric cancer is lower than 10%, despite the development of systemic therapy. Conversion surgery has shown to improve survival outcomes in patients with durable clinical response on chemotherapy. We report a clinical case of a patient, who underwent conversion surgery after pembrolizumab in the third-line setting for stage IV gastric cancer. The patient did not have recurrence for 22 months after conversion surgery.

Conversion Surgery After Chemotherapy Plus Nivolumab as the First-Line Treatment for Unresectable Advanced or Recurrent Gastric Cancer and a Biomarker Study Using the Gustave Roussy Immune Score: A Multicenter Study

BACKGROUND

There are few reports on conversion surgery (CS) after chemotherapy plus nivolumab as a first-line treatment in patients with unresectable advanced or recurrent gastric cancer (GC). This multicenter study was conducted to analyze real-world data on CS after chemotherapy plus nivolumab as a first-line treatment and to identify predictive biomarkers.

METHODS

This multicenter study included 104 patients who received chemotherapy plus nivolumab as primary treatment for unresectable advanced recurrent GC from 12 institutes. We investigated and analyzed patient characteristics and blood test data in the presence or absence of CS, the relationship between the Gustave Roussy Immune Score (GRIm-s) and CS, and the characteristics of CS cases.

RESULTS

CS was performed in 12 patients (11.5%). Eastern Cooperative Oncology Group Performance Status (ECOG-PS) was significantly better in patients who underwent CS (p < 0.0001). There were no CS cases with high-risk GRIm-s (0%), however there were 22 non-CS cases (23.9%). No high-risk GRIm-s cases were converted to CS. Minimally invasive surgery was performed in 50.0% of the cases, with R0 resection in all cases and only one case of urinary retention (Grade II) as a postoperative complication, indicating a good postoperative short-term outcome. There were two cases of postoperative recurrence (16.7%), both of which were grade 1b.

CONCLUSIONS

The short-term postoperative results of CS after chemotherapy plus nivolumab as the first-line treatment for GC were acceptable in this study. There were no high-risk GRIm-s cases among those who underwent CS, suggesting that the GRIm-s may be a predictor of CS.

A comprehensive overview of gastric cancer management from a surgical point of view

Despite advancements in medical care, surgical technologies, and the development of novel treatments over the past decade, the prognosis for patients with gastric cancer (GC) has only modestly improved. This is primarily due to the fact that the majority of patients are diagnosed at advanced stages or present with metastatic disease. Radical resection remains the cornerstone of potentially curative treatment, yet the overall 5-year survival rate remains below 35%. The management of GC varies globally, influenced by factors such as geographical disparities, patient comorbidities and performance status, surgical approaches, and available medical resources. Multidisciplinary collaboration and a multimodal treatment approach are essential for optimizing patient outcomes. Surgeons must stay updated on emerging surgical concepts and make informed decisions regarding patient selection, timing of intervention, and the adoption of appropriate surgical techniques to improve both quality of life and prognosis. This review aims to provide a surgical perspective on the management of GC across all stages, highlighting the importance of a comprehensive treatment approach. Endoscopic resection may be a viable option for early GC in patients with minimal risk of lymph node metastasis, particularly in elderly patients with high surgical risk or severe comorbidities. For advanced GC, neoadjuvant therapy followed by surgery could be a promising strategy to improve patient outcomes. Conversion surgery offers a potential survival benefit for patients who respond to treatment with tumor downstaging. The treatment of peritoneal carcinomatosis remains challenging; however, hyperthermic intraperitoneal chemotherapy combined with complete cytoreductive surgery or pressurized intraperitoneal aerosolized chemotherapy may prolong survival or improve quality of life in highly selected patients.

Gastric cancer and brain metastasis: A systematic review and meta‑analysis

Gastric cancer (GC) constitutes one of the most wide-ranging cancers, with brain metastasis (BM) being a markedly uncommon and unfavorable outcome. The present meta-analysis evaluated the relationship between no-surgical treatment vs. additional surgical BM resection on the patient's quality of life and potential survival using electronic databases, including PubMed (1980-April 2024), Medline (1980-April 2024), Cochrane Library, and EMBASE (1980-April 2024). After a literature search, six articles were included in the final study pool. The number of patients with BM and conservative treatment was 289 (80.05%) compared with those that underwent an additional surgical resection 72 (19.95%). The mean age was 59.2 years, and the males were 195 (73.8%) of 264 available from five studies. The findings of the present meta-analysis revealed that the curative effect of BM tumor resection on patients with GC undergoing additional treatment with stereotactic radiosurgery, whole-brain radiotherapy or chemotherapy was favorable for their survival.

Analysis of the therapeutic effect and influencing factors on unresectable gastric cancer treated with conversion therapy

Background

Gastric cancer (GC) is one of the leading causes of cancer-related death in China, and with the extensive development of conversion therapy, the treatment of advanced unresectable gastric cancer (AUGC) patients has ushered in a new dawn. This study aimed to analyze the efficacy of conversion therapy in AUGC patients and explored the relevant factors affecting the efficacy.

Method

We collected information from GC patients who received conversion therapy from this center and designed a retrospective study.

Results

We collected relevant clinical data from 160 patients with AUGC. A total of 120 patients who underwent routine R0 resection were identified as conversion cases. A total of 25 patients (15.6%) achieved pCR, 92 patients (57.5%) achieved objective response rate (ORR), 140 patients (87.5%) achieved disease control rate (DCR), and 20 cases (12.5%) observed tumor progression. There were 86 patients who achieved pathological downgrading, with a total downgrading rate of 53.8%. Among the 160 patients, 37 patients (23.1%) had postoperative complications of varying degrees. A total of 72 patients (45.0%) had tumor recurrence/progression at the end of follow-up. The last chemotherapy and surgery (CST) (OR = 1.046, 95% CI 1.013-1.081, p = 0.006), tumor invasion (OR = 32.096, 95% CI 5.091-202.349, p < 0.001), and distant metastasis (OR = 7.050, 95% CI 1.888-26.323, p = 0.004) were independent factors influencing the efficacy of conversion therapy.

Conclusion

Conversion therapy may have a good therapeutic efficacy for AUGC, and some clinical factors affect the efficacy response.

Management of HER2-positive and microsatellite instability-high advanced gastric cancer: a case report

Chemotherapy for advanced gastric cancer has progressed significantly in the past few decades. Biomarker-specific drugs, including anti-human epidermal growth factor receptor 2 (HER2) drugs for HER2-positive patients and immune checkpoint inhibitors for those with microsatellite instability-high (MSI-H), have become common. However, patients who are positive for HER2 and have MSI-H are extremely rare, and there are no established treatments for these patients. We present the case of a 75-year-old, male patient with gastric cancer with lymph node metastases and liver infiltration. Biomarker analysis revealed HER2 3 + , loss of MLH1, and MSI-H. After three cycles of S-1, oxaliplatin, and trastuzumab, the primary tumor and metastases shrank markedly. He subsequently underwent gastrectomy and hepatectomy as conversion surgery, achieving a pathologically complete response. He has been recurrence-free for seven months postoperatively. The present case demonstrated the efficacy of trastuzumab-containing chemotherapy followed by conversion surgery in a patient with HER2-positive, MSI-H, advanced gastric cancer.

A feasibility study of modified docetaxel, cisplatin, and capecitabine for advanced gastric cancer followed by gastrectomy

AIMS

To explore the feasibility of modified docetaxel, cisplatin, and capecitabine (mDCX) chemotherapy with a lower dose of docetaxel than previously reported for stage III resectable gastric cancer patients with a high risk of recurrence or for stage IV gastric cancer patients aiming for conversion surgery.

METHODS

Patients with stage III resectable HER2-negative gastric cancer with large type 3 or type 4 tumors or extensive lymph node metastasis (bulky N or cN3) and those who had stage IV HER2-negative gastric cancer with distant metastasis were enrolled to receive 30 mg/m2 docetaxel and 60 mg/m2 cisplatin on day 1, followed by 2000 mg/m2 capecitabine per day for 2 weeks every 3 weeks.

RESULTS

Five patients with stage III gastric cancer with a high risk of recurrence received three courses of mDCX, and four patients with stage IV gastric cancer received three or four courses of mDCX. In terms of grade 3 or worse adverse events, leukopenia was observed in one (11%) patient, neutropenia in two (22%) patients, anemia in one (11%) patient, anorexia in two (22%) patients and nausea in two (22%) patients. All six patients with measurable lesions achieved a partial response. All nine patients underwent subsequent surgeries. The histological responses of the nine patients revealed grade 3 in one (11%) patient, grade 2 in five (56%) patients, and grade 1a in three (33%) patients. Three of the nine patients survived without recurrence, and two of them survived for more than four years.

CONCLUSIONS

mDCX seems to be feasible and may be helpful as neoadjuvant chemotherapy for patients at high risk of recurrence or as chemotherapy for patients who are likely to undergo conversion surgery.

Long intergenic noncoding RNA for IGF2BP2 stability suppresses gastric cancer cell apoptosis by inhibiting the maturation of microRNA-34a

The oncogenic role of long intergenic noncoding RNA for IGF2BP2 stability (LINRIS) has been reported in colorectal cancer. This research aimed to study its potential involvement in gastric cancer (GC). In this study, paired GC and non-tumor tissues were obtained from 64 GC patients, and the levels of LINRIS, mature microRNA-34a (miR-34a), and miR-34a precursor in these tissues were measured with RT-qPCR. Linear regression was used to analyze their correlations. The role of LINRIS overexpression and siRNA silencing in regulating the maturation of miR-34a was analyzed by RT-qPCR. Cell apoptosis was studied with flow cytometry. It was observed that LINRIS was overexpressed in GC and showed a negative correlation with mature miR-34a, but not miR-34a precursor. In GC cells, LINRIS siRNA silencing upregulated mature miR-34a level, but not miR-34a precursor level. LINRIS overexpression downregulated miR-34a level. Cell apoptosis analysis showed that LINRIS siRNA silencing and miR-34a overexpression promoted GC cell apoptosis and suppressed cell migration and invasion, while LINRIS overexpression suppressed cell apoptosis and enhanced cell migration and invasion. In addition, the effect of LINRIS overexpression was reversed by miR-34a overexpression. Therefore, LINRIS siRNA silencing in GC may promote cell apoptosis by promoting miR-34a maturation.

Macroscopic type is implicated in the prognostic impact of initial chemotherapy on peritoneal lavage cytology-positive gastric cancer with no other noncurative factors

BACKGROUND

Initial chemotherapy (Initial-C) followed by surgery is a promising treatment strategy for peritoneal lavage cytology-positive gastric cancer (CY1 GC) with no other noncurative factors. The aim of this study was to investigate the survival advantage of Initial-C compared to initial surgery (Initial-S) for this disease according to the macroscopic type, which was associated with prognosis and the efficacy of chemotherapy in GC.

METHODS

One hundred eighty-nine patients who were diagnosed with CY1 GC with no other noncurative factors at four institutions from January 2007 to December 2018 were enrolled. The patients were divided into a macroscopic type 4 group (N = 48) and a non-type 4 group (N = 141). The influence of initial treatment on overall survival (OS) in each group was evaluated.

RESULTS

In the type 4 group, the 5-year OS rates of Initial-C (N = 35) and Initial-S (N = 13) were 11.6% and 0%, respectively (P = 0.801). The multivariate analysis could not show the survival advantage of Initial-C. In the non-type 4 group, the 5-year OS rates of Initial-C (N = 41) and Initial-S (N = 100) were 48.4% and 29.0%, respectively (P = 0.020). The multivariate analysis revealed that Initial-C was independently associated with prolonged OS (hazard ratio, 0.591; 95% confidence interval, 0.375-0.933: P = 0.023).

CONCLUSIONS

Initial-C improves the prognosis of non-type 4 CY1 GC with no other noncurative factors. On the other hand, further development of effective chemotherapeutic regimens and innovative treatment strategies are required for type 4 CY1 GC.

Minimally Invasive Conversion Surgery for Unresectable Gastric Cancer with Splenic Metastasis and Splenic Vein Tumor Thrombus: A Case Report

While the importance of conversion surgery has increased with the development of systemic chemotherapy for gastric cancer (GC), reports of conversion surgery for patients with GC with distant metastasis and tumor thrombus are extremely scarce, and a definitive surgical strategy has yet to be established. Herein, we report a 67-year-old man with left abdominal pain referred to our hospital following a diagnosis of unresectable GC. Esophagogastroduodenoscopy and contrast-enhanced abdominal computed tomography (CT) revealed advanced GC with splenic metastasis. A splenic vein tumor thrombus (SVTT) and a continuous thrombus to the main trunk of the portal vein were detected. The patient was treated with anticoagulation therapy and systemic chemotherapy comprising S-1 and oxaliplatin. One year following chemotherapy initiation, a CT scan revealed progressive disease (PD); therefore, the chemotherapy regimen was switched to ramucirumab with paclitaxel. After 10 courses of chemotherapy resulting in primary tumor and SVTT shrinkage, the patient underwent laparoscopic total gastrectomy (LTG) and distal pancreaticosplenectomy (DPS). He was discharged without complications and remained alive 6 months postoperatively without recurrence. In summary, the wait-and-see approach was effective in a patient with GC with splenic metastasis and SVTT, ultimately leading to an R0 resection performed via LTG and DPS.

Nomogram models for predicting overall and cancer-specific survival in early-onset gastric cancer patients: a population-based cohort study

To develop nomogram models for predicting the overall survival (OS) and cancer-specific survival (CSS) of early-onset gastric cancer (EOGC) patients. A total of 1077 EOGC patients from the Surveillance, Epidemiology, and End Results (SEER) database were included, and an additional 512 EOGC patients were recruited from the Fourth Hospital of Hebei Medical University, serving as an external test set. Univariate and multivariate Cox regression analyses were performed to identify independent prognostic factors. Based on these factors, two nomogram models were established, and web-based calculators were developed. These models were validated using receiver operating characteristics (ROC) curve analysis, calibration curves, and decision curve analysis (DCA). Multivariate analysis identified gender, histological type, stage, N stage, tumor size, surgery, primary site, and lung metastasis as independent prognostic factors for OS and CSS in EOGC patients. Calibration curves and DCA curves demonstrated that the two constructed nomogram models exhibited good performance. These nomogram models demonstrated superior performance compared to the 7th edition of the AJCC tumor-node-metastasis (TNM) classification (internal validation set: 1-year OS: 0.831 vs 0.793, P = 0.072; 1-year CSS: 0.842 vs 0.816, P = 0.190; 3-year OS: 0.892 vs 0.857, P = 0.039; 3-year CSS: 0.887 vs 0.848, P = 0.018; 5-year OS: 0.906 vs 0.880, P = 0.133; 5-year CSS: 0.900 vs 0.876, P = 0.109). In conclusion, this study developed two nomogram models: one for predicting OS and the other for CSS of EOGC patients, offering valuable assistance to clinicians.

Successful subtotal gastrectomy and hepatectomy for HER2-positive gastric cancer with liver metastasis after trastuzumab-based chemotherapy: a case report

BACKGROUND

Conversion surgery (CS) after chemotherapy is weakly recommended as a promising tool for improving prognoses in patients with unresectable gastric cancer. Moreover, several investigators have demonstrated the clinical efficacy of subtotal gastrectomy (sTG) with a small remnant stomach for the nutritional status and surgical outcome compared with total gastrectomy. Here, we report a patient with liver metastasis from human epidermal growth factor receptor 2 (HER2)-positive gastric cancer who underwent sTG and hepatectomy after trastuzumab-based chemotherapy.

CASE PRESENTATION

An 84-year-old male patient was diagnosed with HER2-positive gastric cancer with a single liver metastasis. He was treated with eight courses of trastuzumab in combination with S-1 and oxaliplatin as first-line chemotherapy. The primary tumor and liver metastasis shrank significantly. The metastatic liver lesion's reduction rate was 65%. According to the Response Evaluation Criteria in Solid Tumors, the patient had a partial response. Therefore, he underwent an sTG with D2 lymphadenectomy and partial hepatectomy of segment 2. Histopathological examination revealed a grade 3 histological response without lymph node metastases from the primary tumor. No viable cancer cells were observed in the resected liver specimens. The patient received adjuvant chemotherapy with S-1. The postoperative quality of life (QOL) evaluated using the Postgastrectomy Syndrome Assessment Scale-45 was maintained, and the patient was still alive 8 months after the CS without recurrence.

CONCLUSIONS

An sTG with a small remnant stomach might be clinically useful for preventing a decline in QOL and improving prognoses in patients with stage IV gastric cancer after chemotherapy.

Oligometastasis of Gastric Cancer: A Review

The concept of oligometastasis is not yet fully established in the field of gastric cancer. However, metastatic lesions that are localized, technically resectable at diagnosis, present a certain response to preoperative chemotherapy, and present favorable survival outcomes with local treatments, sometimes in combination with chemotherapy, are recognized as oligometastasis in the field of gastric cancer. Oligometastasis is noted in European Society for Medical Oncology guidelines and Japanese gastric cancer treatment guidelines, and local treatment is mentioned as one of the pivotal treatment options for oligometastasis. Solitary liver metastasis or a small number of liver metastases; retroperitoneal lymph node metastasis, especially localized para-aortic lymph node metastasis; localized peritoneal dissemination; and Krukenberg tumor are representative types of oligometastasis in gastric cancer. The AIO-FLOT3 trial prospectively evaluated the efficacy of multimodal treatments for gastric cancer with oligometastasis, including surgical resection of primary and metastatic lesions combined with chemotherapy, confirming favorable survival outcomes. Two phase 3 studies are ongoing to investigate the efficacy of surgical resection combined with perioperative chemotherapy compared with palliative chemotherapy. Thus far, the evidence suggests that multimodal treatment for oligometastasis of gastric cancer is promising.

Treatment strategy for successful conversion surgery in clinical stage IVB gastric cancer

INTRODUCTION

Recent advances in chemotherapy have resulted in successful conversion surgery (CS) for clinical stage (cStage) IVB gastric cancer (GC). This study aimed to evaluate the success rate of CS in clinical practice and determine optimal treatment strategies.

METHODS

Totally, 166 patients with cStage IVB gastric and gastroesophageal junction adenocarcinoma, who underwent chemotherapy at Hyogo Medical University Hospital between January 2017 and June 2022, were included. CS was performed after confirming tumor to be M0 based on imaging and/or staging laparoscopy, except for resectable liver metastases. Preoperative chemotherapy was continued for at least 6 months provided that adverse events were manageable.

RESULTS

Of 125 eligible patients, 23 were treated with CS, achieving a conversion rate of 18.4% and an R0 resection rate of 91.3%. The median duration of preoperative chemotherapy was 8.5 months; the median number of cycles was eight. The highest conversion rate was observed in patients receiving first-line treatment (14.4%), followed by those receiving second and third lines (5.8% and 2.3%, respectively). The median survival time in patients who received CS was significantly longer than that in patients who continued chemotherapy alone (56.7 versus 16 months, respectively, P < 0.0001). There was no significant difference in the 3-year overall survival between the patients who achieved CS after first-line treatment (63.2%, n = 18) and those who achieved CS after second- or third-line treatment (66.7%, n = 5).

CONCLUSION

Consistent chemotherapy strategies could lead to successful CS and improved prognosis in a greater number of patients with cStage IVB GC, regardless of line of treatment.

A bibliometric analysis of gastric cancer liver metastases: advances in mechanisms of occurrence and treatment options

BACKGROUND

Gastric cancer (GC) is the fifth most commonly diagnosed cancer worldwide, and its poor prognosis is predominantly attributed to distant metastasis. Liver is the primary site of GC metastasis. However, there is no universally approved treatment regimen for liver metastasis in GC. The aim of this article is to review the current research status and trends of liver metastasis of gastric cancer worldwide.

METHODS

We utilized the Web of Science Core Collection database to identify articles on liver metastasis from GC published between 2000 and 2022. We used bibliometric methods to analyze authors, institutions, countries, journals, and references through CiteSpace and VOSviewer. A total of 1,003 articles were included in this study.

RESULTS

Japan published the most articles in the field, followed by China. Nagoya University is the leading institution in the field of liver metastases in GC. Yasuhiro Kodera from Japan has made significant achievements in this area. We identified Gastric Cancer to be the most influential journal in this field. Using cluster analysis, the keywords were divided into four major clusters:(1) the molecular mechanism of gastric cancer liver metastasis (2) prognosis (3) liver resection (4) chemotherapy.

CONCLUSION

Our study systematically summarizes the results of gastric cancer liver metastasis research from 2000 to 2022 and describes and predicts research hotspots and trends on a global scale. Research on the molecular mechanisms of gastric cancer liver metastasis will become a hot topic in the future, and the expansion of the surgical treatment scope and the advancement of translational therapy will benefit more patients.

Long-Term Complete Response to Trastuzumab Deruxtecan in a Case of Unresectable Gastric Cancer

Introduction

Trastuzumab deruxtecan (T-Dxd) has been approved for the treatment of HER2-positive gastric cancer. However, there are only a limited number of cases of gastric cancer where a long-term complete response (CR) has been maintained. Consequently, we report a case of gastric cancer in which long-term CR was maintained.

Case Presentation

A woman in her late 60s underwent a gastrointestinal endoscopy, which revealed a type 2 lesion with ulceration in the lesser curvature of the vestibule, and a biopsy, which revealed an adenocarcinoma. Computed tomography (CT) revealed wall thickening of the gastric antecubital region, metastatic liver tumor, and extra-regional lymph node metastasis; a diagnosis of T4a, N3a, M1 (H, LYN), and cStage IVB (HER2 3+) was confirmed. Trastuzumab, oxaliplatin, and S-1 were administered initially. After 9 months, ascites appeared, and progressive disease was diagnosed. Paclitaxel and ramucirumab were started as second-line treatments but discontinued owing to neutropenia and increasing ascites. Third-line treatment with T-Dxd was initiated, and 11 months later, CT showed the disappearance of metastases. Even after 31 months, the CR was maintained.

Conclusion

To the best of our knowledge, this is one of the few cases in which long-term CR was maintained with third-line T-Dxd treatment. Treatment strategies for patients with gastric cancer to achieve long-term CR require careful consideration.

A pragmatic approach improves the clinical management of stage IV gastric cancer: Comparison between the Meta-Gastro results and the GIRCG's retrospective series

INTRODUCTION

The Italian Research Group for Gastric Cancer developed a prospective database about stage IV gastric cancer, to evaluate how a pragmatic attitude impacts the management of these patients.

MATERIALS AND METHODS

We prospectively collected data about metastatic gastric cancer patients thanks to cooperation between radiologists, oncologists and surgeons and we analyzed survival and prognostic factors, comparing the results to those obtained in our retrospective study.

RESULTS

Three-hundred and eighty-three patients were enrolled from 2018 to September 2022. We observed a higher percentage of laparoscopic exploration with peritoneal lavage in the prospective cohort. In the registry only 3.6 % of patients was submitted to surgery without associated chemotherapy, while in the retrospective population 44.3 % of patients were operated on without any chemotherapy. At univariate and multivariate analyses, the different metastatic sites did not show any survival differences among each other (OS 20.0 vs 16.10 vs 16.7 months for lymphnodal, peritoneal and hepatic metastases, respectively), while the number of metastatic sites and the type of treatment showed a statistical significance (OS 16,7 vs 13,0 vs 4,5 months for 1, 2 and 3 different metastatic sites respectively, p < 0.001; 24,2 vs 12,0 vs 2,5 months for surgery with/without chemotherapy, chemotherapy alone and best supportive treatment respectively, p < 0.001).

CONCLUSIONS

Our data highlight that the different metastatic sites did not show different survivals, but survival is worse in case of multiple localization. In patients where a curative resection can be achieved, acceptable survival rates are possible. A better diagnostic workup and a more accurate staging impact favorably upon survival.

Conversion surgery after successful response to chemotherapy (S-1 + oxaliplatin + nivolumab) in a patient with stage IV gastric cancer with peritoneal metastasis (P1, CY1): a case report

We here present a case report of a patient with Stage IV gastric cancer with peritoneal metastasis (P1, CY1) who underwent conversion surgery after a successful response to chemotherapy (S-1 + oxaliplatin + nivolumab). The patient was a woman in her 60 s. Her chief complaint was epigastric pain. Upper gastrointestinal endoscopy showed Type 4 advanced carcinoma on the lesser curvature of the gastric body. Biopsy showed Group 5 (poorly differentiated adenocarcinoma) and HER2 was negative. Staging laparoscopy revealed seeding in the round ligament of the liver (P1) and adenocarcinoma cells in ascites (CY1). Ten courses of chemotherapy (S-1 + oxaliplatin + nivolumab) were administered, after which contrast-enhanced computed tomography showed that the primary tumor had shrunk and seeding was no longer detectable. Upper gastrointestinal endoscopy revealed scar-like changes. A second staging laparoscopy revealed that ascites cytology was negative and a biopsy of the round ligament of the liver showed no malignant cells (P0, CY0). Conversion surgery comprising laparoscopic total gastrectomy with D2 lymph node dissection and resection of the round ligament of the liver was performed. The postoperative course was uneventful. Histopathological examination of the resected specimen revealed no tumor cells in the gastric mesentery or the round ligament of the liver. The pathological diagnosis was gastric cancer [M, U, L, Less, Ant, Post, type4, T3(SS), N0, M0 (H0, P0, CY0), ypStage IIA]. Adjuvant chemotherapy (S-1) was commenced. The patient is still alive 7 months later with no evidence of recurrence.

The Clinical Implication of Conversion Surgery in Patients with Stage IV Gastric Cancer Who Received Systemic Chemotherapy

With the advances in chemotherapy and immunotherapy, a small subset of patients may be eligible for conversion surgery after achieving tumor regression with chemotherapy. This is a retrospective cohort study of 118 patients with stage IV gastric cancer who received palliative chemotherapy and conversion surgery with a negative resection margin at Samsung Medical Center. Baseline features included comorbidities, body mass index (BMI), carcinoembryonic antigen (CEA) level, primary tumor size, biopsy histology, distant metastatic sites, and molecular markers-HER2, MSI/MMR, PD-L1, and EBV. Post-chemotherapy features included BMI, CEA level, chemotherapy regimen, objective response to chemotherapy, and number of preoperative chemotherapy cycles. Post-operational features included tumor size, histologic differentiation and Lauren's classification, pathologic tumor and nodal stages, invasion of lymphatics/vessels/nerves, peritoneal cytology, and the receipt of postoperative chemotherapy. Of 118 patients, 60 patients received total gastrectomy and 58 patients received subtotal gastrectomy. In all, 21 patients achieved a pathologic complete response, and 97 patients achieved downstaging to yp stage I, II, or III. Before conversion surgery, patients received first-line capecitabine/oxaliplatin (62%), HER2 inhibitors combined with chemotherapy (18%), immune checkpoint inhibitors (15%), and inhibitors of MET or VEGFR2 (5%). In the multivariable analysis, BMI at the time of diagnosis, either HER2 positive, high MSI, or deficient MMR, and the use of targeted agents were significant prognostic factors. Conversion surgery could be considered in patients with stage IV gastric cancer regardless of the initial disease burden. BMI and molecular markers are important prognostic factors that can be used to select candidates.

Efficacy and long-term prognosis of gastrojejunostomy for malignant gastric outlet obstruction: A systematic review and Bayesian network meta-analysis

BACKGROUND

Gastrojejunostomy (GJ) is becoming a standard surgical treatment for ameliorating malignant gastric outlet obstruction (MGOO). However, data on the long-term outcomes of MGOO treatment are lacking. This network meta-analysis aimed to compare overall survival (OS) rates and subsequent anticancer treatment outcomes of GJwith other therapies in MGOO.

METHODS

We searched four electronic databases, including PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials, from inception to August 1, 2022. Studies reporting OS associated with GJ versus other treatments for MGOO were selected. The study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary outcome assessed was OS, whereas the secondary outcome was subsequent anticancer treatment. We performed a Bayesian network meta-analysis to produce hazard ratios (HR) and odds ratios (OR) with 95% credible intervals (CrIs).

RESULTS

We identified 24 retrospective studies that included 2473 patients. The studies assessed the outcomes of six treatments to alleviate MGOO. Results showed that GJ (hazard ratio: 0.83, 95% CrI: 0.78-0.88) was the most effective treatment for patients with MGOO, with the greatest surface under the cumulative ranking curve (SUCRA) values (79.9%) versus non-resection, palliative chemotherapy (13.9%) in terms of OS. Similarly, GJ (SUCRA: 46.5%) improved subsequent anticancer treatment requirements, ranking second only to jejunostomy/gastrostomy (JT/GT) (SUCRA: 95.9%).

CONCLUSIONS

Our study demonstrates that GJ improves OS and follow-up treatments versus other non-resection treatments in patients with MGOO. These findings may serve for selecting appropriate therapy for MGOO.

Low Expectancy of Conversion Surgery with R0 Resection in Patients with CEA > 5.0 ng/mL at the Initial RECIST Evaluation for Metastatic Gastric Cancer

This retrospective study examined early the predictive factors for successful conversion surgery (CS) with R0 resection in patients with metastatic gastric cancer (MGC) who underwent systemic chemotherapy. This study included 204 patients diagnosed with metastatic gastric adenocarcinoma, who received chemotherapy between 2009 and 2019. Of these patients, 31 (15%) underwent CS with R0 resection. The incidence of CS with R0 resection was not affected by the volume of metastatic lesions or the presence of peritoneal metastasis. The overall survival time of the CS with R0 resection group was significantly longer than that of the non-CS group (hazard ratio, 0.12; 95% confidence interval, 0.07-0.23; p < 0.0001), with a 5 year overall survival rate of 50.2%. Multivariate analysis of 150 patients, excluding those with disease progression until the initial Response Evaluation Criteria in Solid Tumors (RECIST) evaluation, showed that carcinoembryonic antigen > 5.0 ng/mL at the initial RECIST evaluation was an independent, significant, and unfavorable predictor of CS with R0 resection (odds ratio, 0.21; p = 0.0108), whereas systemic chemotherapy with trastuzumab for HER2-positive cancer was a favorable factor (odds ratio, 4.20; p = 0.0119). Monitoring serum carcinoembryonic antigen levels during chemotherapy may be a useful predictor of the CS implementation in patients with MGC.

Efficacy of palliative surgery for gastric cancer patients with peritoneal metastasis who still have residual peritoneal dissemination after chemotherapy

PURPOSE

Gastric cancer patients with peritoneal metastasis (PM) are generally treated with systemic chemotherapy. When PM has disappeared because of chemotherapy, radical gastrectomy (so-called conversion surgery) is usually performed. We have previously reported the efficacy of conversion surgery, but there are no reports examining the efficacy of palliative gastrectomy for patients with residual PM after chemotherapy. The purpose of this study was to investigate the efficacy of palliative surgery for gastric cancer patients with PM who still have residual peritoneal dissemination after chemotherapy.

METHODS

Twenty-five gastric cancer patients with PM confirmed by laparoscopy and who had received chemotherapy but who still had residual PM were included in this study. Among the 25 patients, palliative surgery was performed in 20 patients (PS group) and chemotherapy was continued in 5 patients (CTx group), and their therapeutic outcomes were compared.

RESULTS

In the PS group, total and distal gastrectomies were performed. Clavien-Dindo grade I postoperative complications occurred in two patients (10%). There were no treatment-related deaths. Postoperative chemotherapy was performed all cases. In the PS group, the median survival time (MST) reached 22.5 months, with 1- and 2-year overall survival (OS) rates of 95% and 45%, respectively, whereas in the CTx group, the MST was 15.8 months, and the 1- and 2-year OS rates were 60% and 0%, respectively. The PS group had significantly longer OS than the CTx group (P=0.044).

CONCLUSIONS

Palliative surgery is safe and may prolong survival in gastric cancer patients with residual PM after chemotherapy.

Modified stomach-partitioning gastrojejunostomy for initially unresectable advanced gastric cancer with outlet obstruction: A case report

BACKGROUND

Chemotherapy followed by gastrojejunostomy remains the main treatment for unresectable gastric cancer (GC) in the middle- or lower-third regions with gastric outlet obstruction (GOO). Radical surgery is performed as part of a multimodal treatment strategy for selected patients who respond well to chemotherapy. This study describes a case of successful radical resection with completely laparoscopic subtotal gastrectomy after a modified stomach-partitioning gastrojejunostomy (SPGJ) for obstruction relief, in a patient with GOO.

CASE SUMMARY

During the initial esophagogastroduodenoscopy, an advanced growth was detected in the lower part of the stomach, which caused an obstruction in the pyloric ring. Following this, a computed tomography (CT) scan revealed the presence of lymph node metastases and tumor invasion in the duodenum, but no evidence of distant metastasis was found. Consequently, we performed a modified SPGJ, a complete laparoscopic SPGJ combined with No. 4sb lymph node dissection, for obstruction relief. Seven courses of adjuvant capecitabine plus oxaliplatin combined with Toripalimab (programmed death ligand-1 inhibitor) were administered thereafter. A preoperative CT showed partial response; therefore, completely laparoscopic radical subtotal gastrectomy with D2 lymphadenectomy was performed after conversion therapy, and pathological complete remission was achieved.

CONCLUSION

Laparoscopic SPGJ combined with No. 4sb lymph node dissection was an effective surgical technique for initially unresectable GC with GOO.

Safety and efficacy of laparoscopic digestive tract nutrition reconstruction combined with conversion therapy for patients with unresectable and obstructive gastric cancer

Background

To explore the safety, efficacy, and survival benefits of laparoscopic digestive tract nutrition reconstruction (LDTNR) combined with conversion therapy in patients with unresectable gastric cancer with obstruction.

Methods

The clinical data of patients with unresectable gastric cancer with obstruction who was treated in Fujian Provincial Hospital from January 2016 to December 2019, were analyzed. LDTNR was performed according to the type and degree of obstruction. All patients received the epirubicin + oxaliplatin + capecitabine regimen as conversion therapy.

Results

Thirty-seven patients with unresectable obstructive gastric cancer underwent LDTNR, while thirty-three patients received chemotherapy only. In LDTNR group patients, the proportion of nutritional risks gradually decreased, the rate of severe malnutrition decreased, the proportion of neutrophil-lymphocyte ratio (NLR) <2.5 increased, the proportion of prognosis nutrition index (PNI) ≥45 increased, and the Spitzer QOL Index significantly increased at day 7 and 1 month postoperatively (P<0.05). One patient (6.3%) developed grade III anastomotic leakage and was discharged after the endoscopic intervention. The median chemotherapy cycle of patients in LDTNR group was 6 cycles (2-10 cycles), higher than that in Non-LDTNR group (P<0.001). Among those who received LDTNR therapy, 2 patients had a complete response, 17 had a partial response, 8 had stable disease, and 10 had progressive disease, which was significantly better than the response rate in Non-LDTNR group(P<0.001). The 1-year cumulative survival rates of the patients with or without LDTNR were 59.5% and 9.1%. The 3-year cumulative survival rate with or without LDTNR was 29.7% and 0%, respectively (P<0.001).

Conclusions

LDTNR can improve the inflammatory and immune status, increase compliance with chemotherapy, and have potential benefits in improving the safety and effectiveness of and survival after conversion treatment.

Conversion therapy for massive hepatocellular carcinoma: A case report and literature review

KEY CLINICAL MESSAGE

For potentially resectable HCC, a more aggressive conversion therapy strategy (high-intensity combined with multiple treatment modalities) can be used.

ABSTRACT

Hepatocellular carcinoma (HCC) is the sixth most common malignancy worldwide. The best treatment for HCC is radical surgical resection, but 70%-80% of patients are ineligible for surgery. Although conversion therapy is an established treatment strategy for various solid tumors, there is no uniform protocol for treating HCC. In this case, we present a 69-year-old male patient diagnosed with massive HCC with Barcelona clinical liver cancer (BCLC) stage B. Because of the insufficient volume of the future liver remnant, we believed radical surgical resection was temporarily impossible. Therefore, the patient received conversion therapy, including four cycles of transcatheter arterial embolization (TAE) and hepatic arterial infusion chemotherapy (HAIC-Folfox), lenvatinib (8 mg orally once a day), and tislelizumab (an anti-PD-1 antibody, 200 mg intravenously once every 3 weeks). Fortunately, the patient achieved a good treatment response (smaller lesions and improved liver function) and underwent radical surgery finally. There was no clinical evidence of recurrence at 6 months of follow-up. For potentially resectable HCC, this case reveals that a more aggressive conversion therapy strategy (high-intensity combined with multiple treatment modalities) can be used.

Apatinib combined with SOX regimen for conversion therapy in advanced gastric cancer patients: a retrospective cohort study

BACKGROUND

Recently, many studies have shown that the progress of conversion therapy can provide surgical opportunities for patients with advanced gastric cancer (GC) and bring survival benefits. However, the results of the current study show that the regimen used in conversion therapy is still controversial. Apatinib, as the standard third-line treatment for GC, has an inconclusive status in conversion therapy.

METHODS

This study retrospectively analyzed GC patients admitted to Zhejiang Provincial People's Hospital from June 2016 to November 2019. All patients were pathologically diagnosed, had unresectable factors, and received SOX regimen with or without apatinib as conversion therapy.

RESULTS

A total of 50 patients were enrolled in the study. Altogether 33 patients (66%) received conversion surgery and 17 patients (34%) received conversion therapy without surgery. The median progression-free survival (PFS) between surgery group and non-surgery group were 21.0 versus 4.0 months (p < 0.0001), and the median overall survival (OS) were 29.0 versus 14.0 months (p < 0.0001). In conversion surgery group, 16 patients (16/33) were treated with SOX plus apatinib, and the R0 resection rate was 81.3%; 17 patients (17/33) were treated with SOX regimen along, and the R0 resection rate was 41.2% (p = 0.032). The PFS in the SOX combined with apatinib group was significantly longer than that of SOX group (25.5 versus 16 months, p = 0.045), and the median OS were 34.0 versus 23.0 months (p = 0.048). The addition of apatinib did not increase the incidence of serious adverse reactions throughout the preoperative therapy period.

CONCLUSIONS

Patients with advanced inoperable gastric cancer could benefit probably from conversion chemotherapy and subsequence conversion surgery. Apatinib-targeted therapy combined with SOX chemotherapy may be a safe and feasible option for conversion therapy.

ypTNM staging is a potentially useful prognostic stratification tool in patients with advanced gastric cancer after preoperative chemotherapy

PURPOSE

Although the usefulness of the ypStage in neoadjuvant chemotherapy for advanced gastric cancer (GC) has been reported, whether or not the ypStage is applicable to all GC patients who receive preoperative chemotherapy, including conversion surgery cases, is unclear. Therefore, this retrospective study evaluated the value of the ypTNM staging system in all advanced GC patients who received chemotherapy prior to gastrectomy.

METHODS

A total of 66 patients who underwent chemotherapy prior to gastrectomy for advanced GC at Chiba University Hospital from January 2008 to December 2020 were enrolled in the current study. The prognostic impact of the ypStage on the overall survival (OS) and relapse-free survival (RFS) were examined via univariate and multivariate analyses.

RESULTS

The 5-year OS rates for ypStage I, II, III, and IV were 87.5%, 64.7%, 52.9%, and 28.6%, respectively, while the 5-year RFS rates were 81.3%, 57.4%, 44.4%, and 28.6%, respectively. The univariate analysis revealed that the ypStage was significantly correlated with the OS (p = 0.037) and the ypT status and ypStage showed a significant correlation with the RFS (p = 0.043 and p = 0.021, respectively). The multivariate analysis demonstrated that only the ypStage was an independent prognostic factor for the OS and RFS (p = 0.024 and p = 0.018, respectively).

CONCLUSION

The ypTNM stage may be a useful tool for the risk stratification of all advanced GC patients treated with chemotherapy followed by gastrectomy, including not only neoadjuvant but also conversion surgery cases.

Artificial intelligence annotated clinical-pathologic risk model to predict outcomes of advanced gastric cancer

Background

Gastric cancer with synchronous distant metastases indicates a dismal prognosis. The success in survival improvement mainly relies on our ability to predict the potential benefit of a therapy. Our objective is to develop an artificial intelligence annotated clinical-pathologic risk model to predict its outcomes.

Methods

In participants (n=47553) with gastric cancer of the surveillance, epidemiology, and end results program, we selected patients with distant metastases at first diagnosis, complete clinical-pathologic data and follow-up information. Patients were randomly divided into the training and test cohort at 7:3 ratio. 93 patients with advanced gastric cancer from six other cancer centers were collected as the external validation cohort. Multivariable analysis was used to identify the prognosis-related clinical-pathologic features. Then a survival prediction model was established and validated. Importantly, we provided explanations to the prediction with artificial intelligence SHAP (Shapley additive explanations) method. We also provide novel insights into treatment options.

Results

Data from a total 2549 patients were included in model development and internal test (median age, 61 years [range, 53-69 years]; 1725 [67.7%] male). Data from an additional 93 patients were collected as the external validation cohort (median age, 59 years [range, 48-66 years]; 51 [54.8%] male). The clinical-pathologic model achieved a consistently high accuracy for predicting prognosis in the training (C-index: 0.705 [range, 0.690-0.720]), test (C-index: 0.737 [range, 0.717-0.757]), and external validation (C-index: 0.694 [range, 0.562-0.826]) cohorts. Shapley values indicated that undergoing surgery, chemotherapy, young, absence of lung metastases and well differentiated were the top 5 contributors to the high likelihood of survival. A combination of surgery and chemotherapy had the greatest benefit. However, aggressive treatment did not equate to a survival benefit. SHAP dependence plots demonstrated insightful nonlinear interactive associations among predictors in survival benefit prediction. For example, patients who were elderly, or poor differentiated, or presence of lung or bone metastases had a worse prognosis if they undergo surgery or chemotherapy, while patients with metastases to liver alone seemed to gain benefit from surgery and chemotherapy.

Conclusion

In this large multicenter cohort study, we developed an artificial intelligence annotated clinical-pathologic risk model to predict outcomes of advanced gastric cancer. It could be used to discuss treatment options.

Efficacy of intra-arterial chemotherapy with sequential anti-PD-1 antibody in unresectable gastric cancer: A retrospective real-world study

BACKGROUND

The prognosis of unresectable gastric cancer is poor, while the efficacy of anti-PD antibodies has not been evaluated.

METHODS

Patients with unresectable gastric cancer who received intra-arterial chemotherapy (IAC) with sequential anti-PD-1 antibody as induction therapy in Jinling Hospital were retrospectively analyzed. The primary outcome is R0 resection rate. The secondary outcomes include safety, conversion surgery rate, overall survival (OS) and progression free survival (PFS) after postoperative IAC and anti-PD-1 treatments. Meanwhile, Tumor immunity in the microenvironment (TIME) before and after IAC was comprehensively dissected with multiplex immunofluorescence in order to detect possible mechanisms favoring anti-PD-1 treatment response.

RESULTS

Between May 2019 and October 2020, 36 patients received at least one cycle of IAC with sequential anti-PD-1 antibody in our institution. The objective response was achieved in 28 patients (77.8%). Thirty patients (83.3%) successfully underwent conversion surgery, among which R0 resection was managed in 25/30 patients, and 23.3% (7/30) was assessed as pathological complete remission. During the median follow-up period of 19.7 months, patients who underwent R0 resection displayed superior OS (HR 0.14 [95% CI 0.04-0.50], P < 0.0001) and PFS (HR 0.11 [0.03-0.44], P < 0.0001) than those who did not. Grade 3 adverse events (AEs) were only encountered in 19.4% patients, no grade 4 AEs observed. In TIME analysis, the number of tertiary lymphoid structures (TLSs) (P = 0.004) were greatly induced by IAC, as well as CD8+ T cells (P = 0.011) and PD-1+ cells (P = 0.025). Meanwhile, Tumor associated macrophages shifted towards anti-tumor M1-like subtypes, with CD68+CD163+ M2-like subpopulation significantly decreased (P = 0.04).

CONCLUSION

Preoperative IAC with sequential anti-PD-1 antibody exhibited promising clinical benefit for unresectable gastric cancer with remarkable conversion rate and R0 resection rate, and also prolonged survival as postoperative regimen. TIME transformation induced by ICA might mediate the additive effect with the immune checkpoint inhibitor.

Conversion surgery for stage IV gastric cancer: a multicenter retrospective study

Background

Recent improvements in systemic chemotherapy have provided an opportunity for patients with stage IV gastric cancer (GC) to undergo conversion surgery (CS). The aim of this study was to evaluate the long-term outcomes of patients who underwent CS and to elucidate the prognostic factors for CS in stage IV GC.

Methods

A total of 79 patients who underwent CS with the aim of R0 resection for stage IV GC at six institutions from January 2008 to July 2019 were enrolled. We retrospectively reviewed the clinicopathological data and prognosis.

Results

Of the 79 patients, 23 (31.1%) had initially resectable disease (IR) before chemotherapy, defined as positive for cancer on peritoneal cytology (CY1), resectable hepatic metastasis, or para-aortic lymph node No. 16a2/b1 metastasis. Of the 56 remaining patients with primary unresectable disease, 39 had peritoneal dissemination. R0 resection was accomplished in 63 patients (79.7%). The 3-year OS rates for patients with IR and unresectable disease were 78.3% and 44.5%, respectively. Multivariate analysis showed that IR (P = 0.014) and R0 (P = 0.014) were statistically significant independent prognostic factors for favorable OS. Among patients with peritoneal dissemination alone, OS was significantly better for patients with R0 resection than for patients with R1/2 resection, with the 3-year OS rates of 65.5% and 23.1%, respectively (P = 0.011).

Conclusions

CS is a treatment option for selected patients with stage IV GC. Patients with IR and patients who achieve R0 resection may obtain a survival benefit from CS.

Survival benefit of surgical resection for stage IV gastric cancer: A SEER-based propensity score-matched analysis

BACKGROUND

Gastric cancer (GC) is a major malignancy worldwide, and its incidence and mortality rate are increasing year by year. Clinical guidelines mainly use palliative drug combination therapy for stage IV gastric cancer. In accordance with some small sample studies, surgery can prolong survival. There is no uniform treatment plan for stage IV gastric cancer. This study focused on collecting evidence of the survival benefit of cancer-directed surgery (CDS) for patients with stage IV gastric cancer by analyzing data from a large sample.

METHODS

Data on patients with stage IV gastric cancer diagnosed between 2010 and 2015 was extracted and divided into CDS and no-CDS groups using the large dataset in the Surveillance, Epidemiology, and End Results (SEER) database. With bias between the two groups minimized by propensity score matching (PSM), the prognostic role of CDS was studied by the Cox proportional risk model and Kaplan-Meier.

RESULTS

A total of 6,284 patients with stage IV gastric cancer were included, including 514 patients with CDS who were matched with no-CDS patients according to propensity score (1:1), resulting in the inclusion of 432 patients each in the CDS and no-CDS groups. The results showed that CDS appeared to prolong the median survival time for stage IV gastric cancer (from 6 months to 10 months). Multifactorial analysis showed that poorly differentiated tumors (grades III-IV) significantly affected patient survival, and chemotherapy was a protective prognostic factor.

CONCLUSION

The findings support that CDS can provide a survival benefit for stage IV gastric cancer. However, a combination of age, underlying physical status, tumor histology, and metastatic status should be considered when making decisions about CDS, which will aid in clinical decision-making.

Neoadjuvant Chemo-Radiation Using IGRT in Patients with Locally Advanced Gastric Cancer

The goal of this study was to see how effective and safe neoadjuvant chemoradiation with image-guided IMRT was in patients with locally advanced resectable gastric cancer. Between January 2013 and June 2019, patients with locally advanced (cT3/cT4 or N+) gastric cancer treated with neoadjuvant chemoradiotherapy at PUMCH (Peking Union Medical College Hospital) were retrospectively studied. Using concurrent chemotherapy (Capecitabine alone or XELOX*2 cycles), radiotherapy (IMRT (intensity-modulated radiation therapy) 45 Gy, 25#, 5 weeks) was delivered with IGRT (image-guided radiotherapy) before the start of each weeks therapy to ensure accuracy and repeatability. A total of 95 patients were enrolled in the study, 93 (97.9%) stage cT3/T4 and 85 (89.5%) stage N+. Of these, 85 patients (89.5%) had a tumor located in the upper 1/3 of the stomach, and 93/95 patients (97.9%) completed neoadjuvant chemoradiation, with 80 patients (84.2%) undergoing stomach resection (58 D2 and 22 D1 gastrostomies). Pathology downstaging was found in 68 patients (85.0%), with 66 patients (82.5%) receiving T downstaging and 56 patients (70.0%) receiving N downstaging. There were 11 individuals (13.8%) who had a pathological complete response (PCR). The average period of follow-up was 44.7 months (19-96 months). The 5-year OS (overall survival), LRFS (local recurrence-free survival), and DMFS (distant metastasis free survival) rates of patients were 47.0% (95% CI: 38.6-55.4), 86.55% (95% CI: 79.1-93.99) and 60.71% (95% CI: 51.49-69.93%), respectively. Thirteen (13.7%) patients had grade 3-4 leukopenia, anemia, and thrombocytopenia, while 9 (9.5%) patients had grade 3-4 anemia, and 5 (5.3%) patients had grade 3-4 thrombocytopenia. PCR was found to be a significant predictive factor for OS in multivariate analysis (HR = 11.211, 95% CI: 1.500-83.813, p = 0.024). The method of using IGRT image-guided IMRT (45 Gy, 25 fractions, 5 weeks) combined with concurrent chemotherapy in patients with locally advanced resectable gastric cancer was equally effective when compared to the clinical efficacy of neoadjuvant chemoradiotherapy, with clinical outcomes achieving equal efficacy, with similar PCR rates and high rates of OS, LRFS, and DMFS, as well as good tolerances of concurrent chemoradiotherapy with acceptable side effects.

The clinical effect of conversion surgery for advanced gastric cancer patients with peritoneal metastasis

BACKGROUND

The prognosis of gastric cancer (GC) patients with peritoneal metastasis (PM) is extremely poor. We developed a new promising regimen combining intraperitoneal (i.p.) paclitaxel (PTX) with systemic PTX and S-1 chemotherapy for GC patients with PM. However, the value of conversion surgery (CS) for GC patients with PM remains unclear. This study aimed to clarify the clinical effect of CS from our updated previous report.

METHODS

We retrospectively analyzed 50 GC patients, divided into chemotherapy alone (CTx; n=15) and conversion surgery intervention (CSI; n=35) groups. In the CTx group, chemotherapy was continued in responders, while in the CSI group, surgery was performed in chemotherapy-responders. The primary endpoint was overall survival (OS) of the two groups. The secondary endpoint was the safety of CS.

RESULTS

In the CTx group, 9 of 15 patients (60%) responded to chemotherapy. In the CSI group, PM disappeared in 22 of 35 patients (62.9%), all of whom underwent CS. Post-operative complications occurred in 2 patients (9%) who underwent CS. There were no treatment-related deaths. Regarding OS, there was no significant difference between the two groups [P=0.14; 95% confidence interval (CI), 0.3016-1.197], nor between chemotherapy-responders in the two groups (P=0.059; 95% CI, 0.1473-1.039). However, four patients in the CSI group have survived more than 5 years after CS.

CONCLUSIONS

CS may be a promising treatment strategy for some GC patients with PM who have responded to chemotherapy.

Management of positive peritoneal cytology gastric cancer patients

Prognosis of patients with stage IV gastric cancer remains up to date dramatically poor. A subgroup of these patients has only positive peritoneal cytology in the peritoneal lavage and represents a target issue of the recent ongoing research. The administration of neoadjuvant chemotherapy, either systemic or intraperitoneal or hyperthermic intraoperative peritoneal chemotherapy, with a variety of combinations of drugs has assisted some of these patients to become peritoneal cytology negative, with a significant implication in their prognosis. Staging laparoscopy is widely used to detect occult peritoneal disease and has, therefore, reduced the number of unnecessary laparotomies. However, recent reports point out a low sensitivity of staging laparoscopy and cytological exam in detecting viable cancer cells and focus on the need of more accurate methods of examining the peritoneal fluid by immunohistochemistry or molecular assays. This review focuses on the latest scientific evidence regarding the optimal management of positive peritoneal cytology gastric cancer patients.

A predictive model for early death in elderly patients with gastric cancer: A population-based study

Background

The mean age of gastric cancer (GC) patients has increased due to the aging society. Elderly GC patients with poor physical status tend to develop complications during the treatment courses, which cause early death. This study aimed to identify risk factors and establish nomograms for predicting total early death and cancer-specific early death in elderly GC patients.

Methods

Data for elderly GC patients were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. These patients were randomly assigned to a training cohort and a validation cohort. The univariate logistic regression model and backward stepwise logistic regression model were used to identify independent risk factors for early death. Nomograms were constructed to predict the overall risk of early death and their performance was validated by receiver operating characteristic (ROC) curve, calibration curve, decision curve analyses (DCA), integrated discrimination improvement (IDI), and net reclassification improvement (NRI) in both training and validation cohorts.

Results

Among the 3102 enrolled patients, 1114 patients died within three months from the first diagnosis and 956 of them died due to cancer-specific causes. Non-Asian or Pacific Islander (API) race, non-cardia/fundus or lesser/greater curvature, higher AJCC stage, no surgery and no chemotherapy were all related to a high risk of both all-cause early death and cancer-specific early death. Higher T stage and N0 stage were only positively related to total early mortality, while liver metastasis was only positively related to cancer-specific early mortality. Based on these identified factors, two nomograms were developed for predicting the risk of all-cause and cancer-specific early death, which showed good performance with the AUC of the nomograms were 0.775 and 0.766, respectively. The calibration curves, DCAs, NRI, and IDI also confirmed the value of these nomograms.

Conclusions

These nomogram models were considered a practical tool to identify the early death of elderly GC patients and help provide a more individualized treatment strategy.

The efficient circulating immunoscore predicts prognosis of patients with advanced gastrointestinal cancer

Background

Immunoscore from tumor tissues was initially established to evaluate the prognosis of solid tumor patients. However, the feasibility of circulating immune score (cIS) for the prognosis of advanced gastrointestinal cancers (AGC) has not been reported.

Material and methods

Peripheral venous blood was collected from 64 untreated AGC patients. We utilized flow cytometry to determine several immune cell subpopulations, including CD8⁺ and CD4⁺ T cells, NK cells, and CD4 + CD25 + CD127^low Tregs. The circulating immune score 1 (cIS1) was assessed according to the proportions of CD4⁺, CD8⁺ T cells, and NK cell, whereas circulating immune score 2 (cIS2) was derived from the proportions of CD4⁺, CD8⁺ T cell, and CD4 + CD25 + CD127^low Tregs. The prognostic role of cIS for progression-free survival (PFS) and overall survival (OS) was analyzed using Kaplan–Meier curves and Cox multivariate models. Receiver operating characteristic (ROC) curves were depicted to compare the prognostic values of cIS1 and cIS2.

Results

AGC patients with high cIS1(≥ 2) and cIS2(≥ 2) had significantly longer PFS (cIS1: median PFS, 11 vs. 6.7 months, P = 0.001; cIS2: 12 vs. 5.8 months, P < 0.0001) and OS (cIS1: median OS, 12 vs. 7.9 months, P = 0.0004; cIS2: 12.8 vs. 7.4 months, P < 0.0001) than those with low cIS1 and low cIS2. The areas under ROC curves (AUROCs) of cIS1 and cIS2 for OS were 0.526 (95% confidence interval; 95% CI 0.326–0.726) and 0.603 (95% CI 0.427–0.779, P = 0.332), whereas AUROC of cIS2 for PFS was larger than that of cIS1 0.735 (95% CI 0.609–0.837) vs 0.625 (95% CI 0.495–0.743) (P = 0.04)).

Conclusion

The cIS can be applied to predict the prognosis of untreated AGC patients. Compared with cIS1, cIS2 displayed superior prognostic value for PFS prediction.

Case Report: Complete Remission of a Patient With Metastatic Gastric Cancer Treated With Nivolumab Combined With Chemotherapy After Palliative Surgery

Metastatic advanced gastric cancer, for which treatment strategies are extremely limited, has a poor prognosis. Complete remission is rare. Patients usually lose the opportunity of therapeutic surgery because the lesions cannot be completely removed, although it can greatly prolong their survival time. Palliative surgery usually suggests bad outcomes. In recent years, the immune checkpoint inhibitor (ICI) nivolumab has shown significant efficacy in the treatment of advanced gastric cancer. However, its applicable conditions and optimal withdrawal time remain controversial owing to its low response rate and high incidence of immune-related adverse events. Herein, we introduce a 66-year-old male patient with advanced gastric cancer with multiple liver metastases who underwent laparoscopic total gastrectomy for acute gastric bleeding. The patient received eight cycles of S-1 plus oxaliplatin (SOX) and switched to eight cycles of SOX plus nivolumab combined regimen in a stable state, later achieving complete remission. There was no recurrence for 32 months after the surgery. This is the first reported case of gastric cancer with multiple liver metastases with long-term complete remission with nivolumab treatment after palliative surgery. The potential mechanism of complete remission was discussed through clinical, genomic, and immune characteristics. The patient had a history of psoriasis and was positive for programmed death ligand 1 (PD-L1), and the interaction of TP53 mutation and HER-2 (-) gene may be associated with complete remission.

Identification and Validation of Immune Cells and Hub Genes in Gastric Cancer Microenvironment

Gastric cancer (GC) is the most common malignant tumor in the digestive system, traditional radiotherapy and chemotherapy are not effective for some patients. The research progress of immunotherapy seems to provide a new way for treatment. However, it is still urgent to predict immunotherapy biomarkers and determine novel therapeutic targets. In this study, the gene expression profiles and clinical data of 407 stomach adenocarcinoma (STAD) patients were downloaded from The Cancer Genome Atlas (TCGA) portal, and the abundance ratio of immune cells in each sample was obtained via the “Cell Type Identification by Estimating Relative Subsets of RNA Transcripts (CIBERSORT)” algorithm. Five immune cells were obtained as a result of abundance comparison, and 295 immune-related genes were obtained through differential gene analysis. Enrichment, protein interaction, and module analysis were performed on these genes. We identified five immune cells associated with infiltration and 20 hub genes, of which five genes were correlated with overall survival. Finally, we used Real-time PCR (RT-PCR) to detect the expression differences of the five hub genes in 18 pairs of GC and adjacent tissues. This research not only provides cellular and gene targets for immunotherapy of GC but also provides new ideas for researchers to explore immunotherapy for various tumors.

Outcomes of Conversion Surgery for Metastatic Gastric Cancer Compared with In-Front Surgery Plus Palliative Chemotherapy or In-Front Surgery Alone

The survival benefits of conversion surgery in patients with metastatic gastric cancer (mGC) remain unclear. Thus, this study aimed to determine the outcomes of conversion surgery compared to in-front surgery plus palliative chemotherapy (PCT) or in-front surgery alone for mGC. We recruited 182 consecutive patients with mGC who underwent gastrectomy, including conversion surgery, in-front surgery plus PCT, and in-front surgery alone at Linkou Chang Gung Memorial Hospital from 2011 to 2019. The tumor was staged according to the 8th edition of the American Joint Committee on Cancer. Patient demographics and clinicopathological factors were assessed. Overall survival (OS) was evaluated using the Kaplan−Meier curve and compared among groups. Conversion surgery showed a significantly longer median OS than in-front surgery plus PCT or in-front surgery alone (23.4 vs. 13.7 vs. 5.6 months; log rank p < 0.0001). The median OS of patients with downstaging (pathological stage I−III) was longer than that of patients without downstaging (stage IV) (30.9 vs. 18.0 months; p = 0.016). Our study shows that conversion surgery is associated with survival benefits compared to in-front surgery plus PCT or in-front surgery alone in patients with mGC. Patients who underwent conversion surgery with downstaging had a better prognosis than those without downstaging.

Interest of the Addition of Taxanes to Standard Treatment in First-Line Advanced HER2 Positive Gastroesophageal Adenocarcinoma in Selective Patients

Background

Studies have reported a beneficial role of the addition of trastuzumab to platin-5-FU based chemotherapy in first-line advanced HER2 positive gastroesophageal adenocarcinoma (GEA). However, the effect of taxanes combined with platin-5FU + trastuzumab (PFT) is understudied.

Methods

We performed a retrospective cohort study to evaluate the interest of taxanes among HER2-positive advanced GEA patients treated with PFT. We enrolled HER2-positive advanced GEA patients who underwent treatment between January 2009 to March 2021 in seven hospitals centers in France, treated with PFT alone (S group) or with taxanes + PFT regimen (T group). The primary outcome was progression-free survival (PFS). Also, overall survival (OS), response rate, conversion surgery rate, and safety were evaluated.

Results

Overall, 65 patients received PFT-based therapy, 24 patients in the T group, and 41 patients in the S group. To avoid the selection bias, only those patients presenting an ECOG-PS of 0-1 and synchronous metastasis (21 patients in the T group and 19 patients in the S group) were included for analysis. The median PFS was 9.3 months (95%CI 7.0 to 17.2) in the T group and 5.9 months (95%CI 3.7 to 9.6) in the S group (log-rank p=0.038). Treatment by taxanes was significantly associated with a better PFS in univariate (HR 0.49; 95%CI 0.25 to 0.98, p=0.042) and multivariate Cox regression analysis (HR 0.44; 95%CI 0.21 to 0.94, p=0.033), and IPTW method (HR 0.56; 95% CI 0.34 to 0.91, p=0.019). OS was prolonged (19.0 months (95%CI 7.8 to 45.2) vs 13.0 months (95%CI 5.5 to 14.8), log-rank p=0.033) in favor of the T group. Treatment by taxanes was significantly associated with a better OS in univariate Cox regression analysis (HR 0.49; 95%CI 0.21 to 0.96, p=0.038) and IPTW method (HR 0.49; 95% CI 0.29 to 0.84, p=0.009). The response rate was higher in the T group, with conversion surgery in five patients. No treatment-related death was observed in both groups.

Conclusions

Given the improvement in PFS and OS, the addition of taxanes to standard chemotherapy could be considered as a promising treatment for selected HER2-positive advanced GEA patients, with PS 0-1 and synchronous metastasis (NCT04920747).

Conversion Surgery in Gastric Cancer Carcinomatosis

BACKGROUND

After the REGATTA trial, patients with stage IV gastric cancer could only benefit from chemotherapy (CHT). However, some of these patients may respond extraordinarily to palliative chemotherapy, converting their disease to a radically operable stage. We present a single centre experience in treating peritoneal carcinomatosis from gastric cancer.

METHODS

All patients with stage IV gastric cancer with peritoneal metastases as a single metastatic site operated at a single centre between 2005 and 2020 were included. Cases were grouped according to the treatment received.

RESULTS

A total of 118 patients were considered, 46 were submitted to palliative gastrectomy (11 were considered M1 because of an unsuspected positive peritoneal cytology), and 20 were submitted to Hyperthermic Intraperitoneal Chemotherapy (HIPEC) because of a <6 Peritoneal Cancer Index (PCI). The median overall survival (OS) after surgery plus HIPEC was 46.7 (95% CI 15.8-64.0). Surgery (without HIPEC) after CHT presented a median OS 14.4 (8.2-26.8) and after upfront surgery 14.7 (10.9-21.1). Patients treated with upfront surgery and considered M1 only because of a positive cytology, had a median OS of 29.2 (25.2-29.2). The OS of patients treated with surgery plus HIPEC were 60.4 months (9.2-60.4) in completely regressed cancer after chemotherapy and 31.2 (15.8-64.0) in those partially regressed (p = 0.742).

CONCLUSIONS

Conversion surgery for peritoneal carcinomatosis from gastric cancer was associated with long survival and it should always be taken into consideration in this group of patients.