Phase II trial of preoperative S-1 plus cisplatin followed by surgery for initially unresectable locally advanced gastric cancer

Efficacy of conversion surgery on stage IV gastric cancer and its prognosis analysis

BACKGROUND

The aim of this study was to explore the clinical efficacy and safety of conversion surgery in the treatment of stage IV gastric cancer, and to analyze the influencing factors for the prognosis of patients.

METHODS

The clinical data of 84 patients with stage IV gastric cancer treated in our hospital from September 2014 to March 2016 were collected. All patients were treated with S-1 + oxaliplatin or S-1 + docetaxel chemotherapy, among which 42 patients had surgical indications after chemotherapy and received gastrectomy (R0 resection or R1 resection) (conversion surgery group); the remaining 42 patients had no surgical indications after chemotherapy (simple chemotherapy group). The patients in both groups were followed-up to record the survival status; moreover, the possible influencing factors for the prognosis were analyzed.

RESULTS

In the conversion surgery group, the median chemotherapy cycle was 4.3, and the objective response rate (ORR) was 73.8% (31/42). During chemotherapy in the two groups, there were 22 cases (52.3%) and 24 cases (57.1%) of hematological toxicity, and 28 cases (66.7%) and 32 cases (76.2%) of non-hematological toxicity, mainly in grade I-II, which could be relieved after symptomatic treatment, and chemotherapy was successfully completed. After chemotherapy, 42 out of 84 patients met the surgical indications. All patients were followed-up for 6-36 months. The 3-year overall survival was 35.7% (15/42) and 9.5% (4/42), respectively, in the two groups, and the difference was statistically significant according to the log-rank test (P<0.05). The results of multivariate analysis showed that whether the surgical margin was R0 was an independent influencing factor for the prognosis of patients (HR=8.012, 95% CI: 2.522-14.384, P=0.027).

CONCLUSIONS

Radical surgery after conversion therapy can raise the survival rate of patients, with tolerable adverse reactions. Whether the surgical margin is R0 in conversion therapy it is an independent influencing factor for the prognosis of patients with stage IV gastric cancer.

Efficacy of continuous gastric artery infusion chemotherapy in relieving digestive obstruction in advanced gastric cancer

BACKGROUND

Obstruction or fullness after feeding is common in gastric cancer (GC) patients, affecting their nutritional status and quality of life. Patients with digestive obstruction are generally in a more advanced stage. Existing methods, including palliative gastrectomy, gastrojejunostomy, endoluminal stent, jejunal nutrition tube and intravenous chemotherapy, have limitations in treating these symptoms.

AIM

To analyze the efficacy of continuous gastric artery infusion chemotherapy (cGAIC) in relieving digestive obstruction in patients with advanced GC.

METHODS

This study was a retrospective study. Twenty-nine patients with digestive obstruction of advanced GC who underwent at least one cycle of treatment were reviewed at The Second Affiliated Hospital of Zhejiang University School of Medicine. The oxaliplatin-based intra-arterial infusion regimen was applied in all patients. Mild systemic chemotherapy was used in combination with local treatment. The clinical response was evaluated by contrast-enhanced computed tomography using Response Evaluation Criteria In Solid Tumors (RECIST) criteria. Digestive tract symptoms and toxic effects were analyzed regularly. A comparison of the Karnofsky Performance Status (KPS) score and Stooler’s Dysphagia Score before and after therapy was made. Univariate survival analysis and multivariate survival analysis were also performed to explore the key factors affecting patient survival.

RESULTS

All patients finished cGAIC successfully without microcatheter displacement, as confirmed by arteriography. The median follow-up time was 24 mo (95%CI: 20.24-27.76 mo). The overall response rate was 89.7% after cGAIC according to the RECIST criteria. The postoperative Stooler’s Dysphagia Score was significantly improved. Twenty-two (75.9%) of the 29 patients experienced relief of digestive obstruction after the first two cycles, and 13 (44.8%) initially unresectable patients were then considered radically resectable. The median overall survival time (mOS) was 16 mo (95%CI: 9.32-22.68 mo). Patients who received radical surgery had a significantly longer mOS than other patients (P value < 0.001). Multivariate Cox regression analysis indicated that radical resection after cGAIC, intravenous chemotherapy after cGAIC, and immunotherapy after cGAIC were independent predictors of mOS. None of the patients stopped treatment because of adverse events.

CONCLUSION

cGAIC was effective and safe in relieving digestive obstruction in advanced GC, and it could improve surgical conversion possibility and survival time.

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.

S-1 Combined With Apatinib and Trans-arterial Chemotherapy and Embolization for Conversion Therapy of Unresectable Locally Advanced Gastric Cancer

BACKGROUND

Conversion therapy is a promising option for unresectable locally advanced gastric cancer (GC) patients. This study aimed to investigate the feasibility and efficacy of conversion therapy based on S-1, apatinib combined with transarterial chemotherapy and embolization (TACE).

MATERIALS AND METHODS

Twenty eligible unresectable locally advanced GC patients were enrolled in this single-arm, single-center, prospective clinical trial. Apatinib was administered orally at 0.5 g once daily and continuously for 58 d, while S-1 twice daily on d 1-14 was given at a dose calculated according to the body surface area and repeated every 3 wk for three cycles. TACE (oxaliplatin 80 mg/m² and etoposide 80 mg/m²) was performed on d 1 and was repeated on d 31.

RESULTS

Nineteen patients completed conversion therapy and no treatment-related deaths occurred. The objective response rate (ORR) was 94.7% (18/19) and noncurative factors had resolved in 13 patients (68.4%) based on imaging estimation. 18 patients received laparoscopic examination and 12 cases underwent definitive surgery. Based on the intraoperative and postoperative pathological examination, 10 patients received radical resection (R0 + D2/D2+). The patients who underwent the conversion surgery had a superior median overall survival (OS) compared with those who did not (P = 0.010).

CONCLUSIONS

S-1 combined with apatinib and TACE regimen is feasible for preoperative treating initial unresectable locally advanced GC patients with high rates of objective response and radical resection which may provide a survival benefit.

Efficacy of Conversion Surgery Following Apatinib Plus Paclitaxel/S1 for Advanced Gastric Cancer With Unresectable Factors: A Multicenter, Single-Arm, Phase II Trial

Objective: Conversion therapy (surgical resection after chemotherapy) is a promising option for unresectable gastric cancer (GC) patients. Addition of anti-angiogenesis drug improves response to chemotherapy. Hence, this study explored the feasibility and efficacy of preoperative paclitaxel (PTX)/S1 chemotherapy combined with apatinib for unresectable GC. Methods: Thirty-one eligible patients with a single unresectable factor were enrolled in this multi-center, single-arm trial. Apatinib (500 mg qd) was administered continuously, while PTX (130 mg/m²) on day 1 and S1 (80 mg/m²) on day 1-14 were given every 3 weeks. The treatment was given for three cycles preoperatively, but the last cycle did not include apatinib. The primary objective measurements included R0 resection rate, objective response rate (ORR) and morbidity of preoperative treatment. Results: Among the 31 patients, 30 patients were evaluable for tumor response, the ORR to preoperative treatment was 73.3%. Eighteen of 30 patients underwent surgery, and R0 resection was achieved in 17 patients. The patients who underwent the conversion surgery had a superior OS compared with those who did not (3 years OS: 52.9 vs 8.3%, p = 0.001). The surgery was operated after apatinib had stopped for a median duration of 4 weeks. Neither anastomotic leakage nor wound healing complications was observed. No increased bleeding event was observed compared with historical data. During preoperative treatment, grade 3 or 4 toxicities were experienced by 58.1% of the patients. Conclusion: Chemotherapy in combination with apatinib demonstrated higher rates of conversion and R0 resection and a superior survival benefit in initial unresectable GC. It is safe and reasonable to suspend apatinib for 4 weeks before the gastrectomy.

Prognostic Value of the Site of Distant Metastasis and Surgical Interventions in Metastatic Gastric Cancer: A Population-Based Study

BACKGROUND

Studies on the prognostic significance of site-specific distant metastasis, multiple-site metastases, and the impact of surgery of the primary tumor and metastatic lesion on survival outcomes of patients with metastatic gastric cancer (GC) remain elusive. Therefore, this study aimed to investigate the prognostic significance of the site of distant metastasis among patients with metastatic GC. Furthermore, the effect of surgery of the primary tumor and metastatic lesion on the prognosis of metastatic GC was also analyzed.

METHODS

The data of 4,221 eligible patients, who were diagnosed with metastatic GC between 2010 and 2015, were identified from the Surveillance Epidemiology and End Results (SEER) database. Multivariate logistic regression analysis was performed to assess the association between potential prognostic factors, including the site of metastasis and surgery, and survival of patients with metastatic GC. Overall survival (OS) and cause-specific survival (CSS) were determined using the Kaplan-Meier survival curves and differences were assessed using the Log-rank test.

RESULTS

Out of the total 4,221 GC patients with definite organ metastases, 3312 patients had single-site metastasis while 909 patients had multiple-site metastases. GC patients with single-site metastasis of liver or lung exhibited better CSS and OS compared to those with bone metastasis. Furthermore, GC patients with liver metastasis benefited from surgery of both the primary and metastatic lesions, while those with lung metastasis benefited from surgery of metastasis resection only. Multivariate Cox regression analysis revealed that GC patients with single-site metastasis, well-differentiated tumors, GC patients who underwent surgery of the primary tumor and those who received chemotherapy exhibited favorable prognosis.

CONCLUSIONS

The site of metastasis was an independent prognostic factor for metastatic GC. Surgery had survival benefits in certain cases of metastatic GC; however, further studies are warranted to clarify these benefits in carefully selected patients.

Differential gene expression in growth factors, epithelial mesenchymal transition and chemotaxis in the diffuse type compared with the intestinal type of gastric cancer

Gastric cancer (GC) is a highly heterogeneous disease and one of the major causes of cancer-related mortality worldwide. Diffuse-type gastric adenocarcinoma (or poorly cohesive- with independent cells) is characterized by aggressive behavior (rapid invasion, chemoresistance and peritoneal metastasis), as compared with intestinal-subtype adenocarcinoma. Diffuse subtype GC additionally has a substantially increasing incidence rate in Europe and the USA, and was often associated with younger age. Our objective was to analyze the expression and clinical significance of genes involved in several signaling pathways in diffuse-type GC. Tumors samples and non-malignant gastric tissues were obtained from patients with GC (diffuse-type and intestinal-subtype adenocarcinoma). The expression of 33 genes coding for proteins involved in four categories, growth factors and receptors, epithelial-mesenchymal transition, cell proliferation and migration, and angiogenesis was determined by reverse transcription-quantitative polymerase chain reaction. The expression of 22 genes was significantly upregulated in diffuse-type GC and two were downregulated (including CDH1) compared with normal tissues. Among these genes, acompared with intestinal-subtype adenocarcinoma, diffuse-type GC revealed elevated levels of IGF1 and IGF1R, FGF7 and FGFR1, ZEB2, CXCR4, CXCL12 and RHOA, and decreased levels of CDH1, MMP9 and MKI67. The expression of selected genes was compared with other genes and according to clinical parameters. Furthermore, TGF-β expression was significantly increased in linitis, a sub-population of diffusely infiltrating type associated with extensive fibrosis and tumor invasion. Our study identified new target genes (IGF1, FGF7, CXCR4, TG-β and ZEB2) whose expression is associated with aggressive phenotype of diffuse-type GC.

Pathological complete response from oral chemotherapy combined with trans-arterial chemotherapy and embolization in an unresectable gastric cancer patient: A case report

RATIONALE

Gastric cancer is still one of the most common cancer in East Asia. More than 70% gastric cancer patients are diagnosed at an advanced stage in China. Moreover, about 10% cases are unresectable which usually suffer a poor prognosis with a median survival time of 5 to 12 months. In recent years, some clinical studies found that many unresectable gastric cancer cases could get opportunity for surgery after treatment that improve prognosis significantly PATIENT CONCERNS:: 64-year-old male patient was admitted with upper abdominal pain. Upper gastrointestinal endoscopy showed a large ulcerated tumor located from the cardia to the anterior wall of the upper gastric body. Histopathological examination showed it was moderately differentiated adenocarcinoma. Computed tomography (CT) scan image showed a large bulging mass with internal ulcer at the lesser curvature wall, left gastric artery and coeliac trunk were surrounded by fused lymph nodes.

DIAGNOSES

Based on the histopathological examination and imaging findings, patient was diagnosed advanced gastric cancer and hardly to resect radically.

INTERVENTION

Oral chemotherapy combined with trans-arterial chemotherapy and embolization (TACE) was initiated. Eight weeks after initial therapy, radical laparoscopy-assisted total gastrectomy with D2 lymph node dissection and Roux-en-Y anastomosis were performed successfully.

OUTCOMES

Patient was discharged on postoperative day 11 without complications. Histological analysis of the specimen and resected 31 lymph nodes revealed no malignancy. The patient experienced a pathological complete response (pCR).

LESSONS

In this case, oral chemotherapy combined with TACE which was rarely reported in the treatment of unresectable gastric cancer achieves a great therapeutic benefit. Although further clinical studies will be needed to establish, it may be a potent strategy for degrading stage and supplying a new chance for surgery.

Efficacy of preoperative chemotherapy regimens in patients with initially unresectable locally advanced gastric adenocarcinoma: capecitabine and oxaliplatin (XELOX) or with epirubicin (EOX)

Purpose We assessed the effectiveness of EOX (capecitabine, oxaliplatin and epirubicin) compared with XELOX (capecitabine and oxaliplatin) as preoperative chemotherapy for initially unresectable locally advanced gastric cancer.Methods This is a prospective observational study. Patients with unresectable locally advanced gastric cancer were performed EOX regimen or XELOX regimen at the discretion of the investigators. They were assessed for response every 2 cycles by CT (computed tomography) scan. A multidisciplinary team reassessed resectability after 4 cycles. The primary endpoint was the response rate. Secondary end points included the R0 resection rate, survival and adverse events.Results From November 2008 to May 2015, 242 patients were enrolled; 112 of them were assigned to EOX regimen and 130 to XELOX regimen. The response rates were 33.0% and 33.8% respectively in EOX group and XELOX group (P = 0.997). After 4 cycles of chemotherapy, 63 patients (56.3%) in EOX group and 81 patients (62.3%) in XELOX group received radical operation (P = 0.408). There was no significant difference in progress-free survival (PFS, 12.0m vs. 15.4m, P = 0.925) and overall survival (OS, 25.7m vs. 29.0m, P = 0.783) in two groups. In addition, more adverse effects occurred in EOX group, such as more leucopenia (22.3% vs. 10.0%, P = 0.014), neutropenia (23.2% vs. 11.5%, P = 0.025), fatigue (11.6% vs. 3.8%, P = 0.041) and vomiting (10.7% vs. 2.3%, P = 0.015).Conclusions For unresectable locally advanced gastric cancer patients, XELOX regimen showed similar effects in response rate, radical resection rate and survival benefits, but with less toxicity effects.

Incidence of and risk factors for preoperative deep venous thrombosis in patients undergoing gastric cancer surgery

BACKGROUND

Pulmonary thromboembolism (PE) is one of the life-threatening complications of gastric cancer surgery. D-dimer assay is a safe and rapid tool to exclude the presence of deep venous thrombosis (DVT). In July 2012, we started preoperative DVT screening of patients scheduled for gastric cancer surgery using a combination of D-dimer measurements and lower extremity venous ultrasonography to prevent PE.

METHODS

Between July 2012 and August 2015, 976 consecutive patients underwent gastric cancer surgery with preoperative D-dimer screening. Lower extremity venous ultrasonography was performed in patients with a positive D-dimer assay result (greater than 1.0 μg/ml). The incidence of and risk factors for preoperative DVT and the incidence of PE were examined in patients undergoing gastric cancer surgery.

RESULTS

Of the 976 patients, 176 (18.0%) showed positive D-dimer assay results, and in 13 (1.3%) DVT was diagnosed by lower extremity ultrasonography. Our analysis identified neoadjuvant chemotherapy as a risk factor for preoperative detection of DVT in patients undergoing gastric cancer surgery (P = 0.021). The incidence of PE was 0.1% (1/976).

CONCLUSION

Preoperative gastric cancer patients receiving neoadjuvant chemotherapy seem to be at higher risk for the development of DVT.

Will molecular target agents enable the multidisciplinary treatment in stage IV gastric cancer?

A detailed molecular characterization of gastric cancer has been revealed by global initiatives and a number of new molecular agents are under investigation. Currently only trastuzumab, a monoclonal antibody for human epidermal growth factor receptor 2 (HER2), is clinically used for HER2 positive advanced gastric cancer patients and ramucirumab, a monoclonal antibody directed against the extracellular ligand-binding domain of vascular endothelial growth factor receptor (VEGFR)2, can be used in second line. However, despite the progress in gastric cancer treatment, the prognosis of stage IV gastric cancer patients remains dismal. To achieve a remarkable improvement in the prognosis of patients, a multidisciplinary treatment approach with the help of effective molecular target agents should be considered. So far the role of multidisciplinary treatment for stage IV gastric cancer is still uncertain due to limited available data and absence of long-lasting tumor control with systemic therapy. Herein, an overview of the latest developments of molecular targeted agents for gastric cancer in advanced stages, in the perioperative setting and in oligometastatic disease is provided. The possibility of a multidisciplinary strategy using molecular target agents and surgery for stage IV gastric cancer is also assessed.

Clinical efficacy of neoadjuvant chemotherapy regimens FLEEOX vs. XELOX in patients with initially unresectable advanced gastric cancer: a propensity score analysis

Purpose

This study was designed to assess the effectiveness of FLEEOX (5-Fu, leucovorin, etoposide, oxaliplatin, and epirubicin) compared with XELOX (capecitabine and oxaliplatin) as neoadjuvant chemotherapy (NAC) for initially unresectable advanced gastric cancer (AGC).

Methods

This study reviewed patients who underwent FLEEOX or XELOX for initially unresectable AGC. To reduce the bias in patient selection, we conducted propensity score match (PSM) with 1:1 ratio. Tumor and pathological response, surgical characteristics, chemotherapy-related toxicity and overall survival (OS) were analyzed.

Results

From January 2004 to December 2012, 436 patients were enrolled; 99 pairs of patients were generated after PSM. The tumor response rates were 80.8% and 68.7% in FLEEOX and XELOX (P=0.018). 80 patients (80.8%) in FLEEOX and 63 (63.6%) in XELOX received radical resection (P<0.001). The pathological complete response rate and R0 rate were 11.1% and 69.7% in FLEEOX, respectively, while 4.8% and 38.4% in XELOX (P<0.001). Median OS time was longer in FLEEOX (30.0 vs. 25.1 months, P<0.001). In addition, more toxicities occurred in FLEEOX, including leukocytopenia (17.2% vs. 7.1%, P=0.024), nausea (17.2% vs. 6.1%, P=0.012) and vomiting (22.2% vs. 10.1%, P=0.016). The overall toxicity rate was higher in FLEEOX (71.7% vs. 35.4%, P<0.001).

Conclusion

The FLEEOX regimen as NAC for patients with initially unresectable AGC can improve tumor response rate, radical resection rate, R0 rate, and OS as compared to XELOX regimen. More chemotherapy-related toxicity was observed in FLEEOX group, although no chemotherapy-related deaths and aborting were observed. Further randomized clinical trials on the FLEEOX regimen are necessary.

Phase II Study of Induction Chemotherapy with Docetaxel, Capecitabine, and Cisplatin Plus Bevacizumab for Initially Unresectable Gastric Cancer with Invasion of Adjacent Organs or Paraaortic Lymph Node Metastasis

Purpose

The purpose of this study was to evaluate the efficacy and safety of induction chemotherapy with docetaxel, capecitabine, and cisplatin (DXP) plus bevacizumab (BEV) on initially unresectable locally advanced gastric cancer (LAGC) or paraaortic lymph node (PAN) metastatic gastric cancer (GC).

Materials and Methods

Patients with LAGC or unresectable PAN metastatic GC received six induction chemotherapy cycles (60 mg/m² docetaxel intravenously on day 1, 937.5 mg/m² capecitabine orally twice daily on days 1-14, 60 mg/m² cisplatin intravenously on day 1, and 7.5 mg/kg BEV intravenously on day 1 every 3 weeks), followed by conversion surgery. The primary endpoint was R0 resection rate.

Results

Thirty-one patients with invasion to adjacent organs but without PAN metastasis (n=14, LAGC group) or with PAN metastasis regardless of invasion (n=17, PAN group) were enrolled between July 2010 and December 2014. Twenty-seven patients (87.1%) completed six chemotherapy cycles. The most common grade ≥ 3 toxicities were neutropenia (71%), neutropenia with fever/infection (22.6%/3.2%), and stomatitis (16.1%). The clinical response and R0 resection rates were 64.3% (95% confidence interval [CI], 46.6 to 82.0) and 64.5% (LAGC group, 71.4%; PAN group, 58.8%), respectively. The pathological complete regression rate was 12.9%. After a median follow-up of 44.5 months (range, 39.4 to 49.7 months), the median progression-free survival and overall survival were 13.1 months (95% CI, 8.9 to 17.3) and 38.6 months (95% CI, 22.0 to 55.1), respectively.

Conclusion

Induction chemotherapy with DXP+BEV displayed antitumor activities with encouraging R0 resection rate and manageable toxicity profiles on patients with LAGC or PAN metastatic GC.

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.

Current situation and new advances in perioperative treatment of gastric cancer

Gastric cancer is one of the most common malignant tumors in the world, and radical surgery is still the most effective treatment. Since gastric cancer screening is not popular in China and early cases are usually asymptomatic, advanced gastric cancer accounts for the vast majority. The prognosis of patients with advanced gastric cancer after surgery alone is still poor. With regard to improving the long-term survival of patients with advanced gastric cancer, the importance of multimodality therapy has been gradually recognized. Perioperative treatment is an important part of multimodality therapy. Nowadays, the perioperative treatment for advanced gastric cancer consists of preoperative chemotherapy, preoperative chemoradiotherapy, targeted therapy, and immune therapy.

Application of conversion therapy in advanced gastric cancer

Patients with advanced gastric cancer (AGC) have short overall survival and poor prognosis. Current guidelines recommend palliative treatments. The success of conversion therapy in liver metastases of colorectal cancer gives an inspiration to AGC treatment. Some small sample studies indicated that conversion therapy provided AGC patients longer overall survival time compared to those who received palliative treatments. The application of conversion therapy in AGC is still lack of effective evidence of evidence-based medicine. The multidisciplinary team (MDT) mode is an important guarantee for the conversion therapy of AGC. The conversion therapy of AGC requires multi-disciplinary comprehensive treatment. This article makes a comprehensive discussion on the choice of cases, treatment plans and timing of treatment from the perspective of nonsurgical treatment, with an aim to provide a reference for clinical treatments.

Survival results of a randomised two-by-two factorial phase II trial comparing neoadjuvant chemotherapy with two and four courses of S-1 plus cisplatin (SC) and paclitaxel plus cisplatin (PC) followed by D2 gastrectomy for resectable advanced gastric cancer

BACKGROUND

The prognosis for stage III gastric cancer is unsatisfactory by D2 gastrectomy and S-1 adjuvant chemotherapy. Both S-1 plus cisplatin (SC) and paclitaxel plus cisplatin (PC) are promising regimens as neoadjuvant chemotherapy; however, the optimal duration remains unclear.

PATIENTS AND METHODS

In this 2×2 randomised phase II trial, stage III gastric cancer patients, those with a prognosis corresponding to stage III, and macroscopically resectable stage IV cases were randomised to two or four courses of S-1 (80 mg/m(2) for 21 d with 1 week rest)/cisplatin (60 mg/m(2) at day 8) or PC (80 and 25 mg/m(2), respectively, on days 1, 8, and 15 with 1 week rest) as neoadjuvant chemotherapy. The primary end-point was the 3-year overall survival (OS).

RESULTS

Between October 2009 and July 2011, 83 patients received 2 courses of SC (n=21), 4 courses of SC (n=20), 2 courses of PC (n=21) and 4 courses of PC (n=21). The 3-year OS was 60.9% for SC and 64.3% for PC and 64.3% for the two courses and 61.0% for the four courses. Subset analyses demonstrated no subgroup which showed any potential survival benefit by PC in comparison to SC or by four courses as in comparison to two courses.

CONCLUSIONS

Two courses of SC as neoadjuvant chemotherapy are recommended as a test arm of a future phase III study for patients with locally advanced gastric cancer.

CLINICAL TRIAL NUMBER

UMIN-000002595.

Conversion therapy for unresectable gastric cancer

Unresectable gastric cancer cases are often diagnosed at a far advanced stage, which are hard to resect radically and suffer a poor prognosis. Therefore, palliative chemotherapy is recommended as the main treatment by the current clinical guidelines for gastric cancer. Fortunately, in recent years some clinical studies revealed that after treatment with chemotherapy, radiotherapy, targeted therapy, interventional therapy, hyperthermic intraperitoneal chemotherapy (HIPEC) and so on, and multidisciplinary assessment, many unresectable gastric cancer cases could be converted into resectable cases, which consequently prolongs their survival time and improves their quality of life significantly. In the present review, we summarize the status and progress of treatment for unresectable gastric cancer, as well as the strategy and case selection for conversion therapy.

Neoadjuvant chemotherapy followed by surgery in gastric cancer patients with extensive lymph node metastasis

Gastric cancer with extensive lymph node metastasis (ELM) is usually considered unresectable and is associated with poor outcomes. Cases with clinical enlargement of the para-aortic lymph nodes and/or bulky lymph node enlargement around the celiac artery and its branches are generally dealt with as ELM. A standard treatment for gastric cancer with ELM has yet to be determined. Two phase II studies of neoadjuvant chemotherapy followed by surgery showed that neoadjuvant chemotherapy with S-1 plus cisplatin followed by surgical resection with extended lymph node dissection could represent a treatment option for gastric cancer with ELM. However, many clinical questions remain unresolved, including the criteria for diagnosing ELM, optimal regime, number of courses and extent of lymph node dissection.

A phase II study of neoadjuvant chemotherapy with S-1 and cisplatin for stage III gastric cancer: KUGC03

OBJECTIVES

A multi-center phase II study was conducted to evaluate the safety and efficacy of neoadjuvant chemotherapy (NAC) with S-1 plus cisplatin for advanced gastric cancer.

METHODS

The eligibility criteria were clinical T3/T4 or N2, not Stage IV. Patients received two 35-day cycles of S-1 plus cisplatin, and then underwent D2 gastrectomy. The primary endpoint was 3-year progression free survival (PFS). Secondary endpoints were ratio of R0 resection, response rate, adverse events, and overall survival. A sample size of 49 was determined to have 80% power for detecting 15% improvement in the 3-year PFS over 55% at a one-sided alpha of 0.1.

RESULTS

Among 53 patients enrolled, 44 patients completed two cycles of NAC (83%), and 48 patients underwent R0 resection (91%). Postoperative complications occurred in 13 patients (26%). A pathological response was confirmed in 24 patients (45%), including four complete responses. The 3-year PFS was 50.7%, while the 3-year OS was 74.9%.

CONCLUSIONS

Although the observed 3-year PFS rate was worse than expected, NAC with S1 plus cisplatin was safe and led to a high rate of R0 resection. A randomized controlled trial is needed to make conclusions about the effectiveness of NAC in Japanese patients undergoing D2 resection.

Salvage surgery after chemotherapy with S-1 plus cisplatin for α-fetoprotein-producing gastric cancer with a portal vein tumor thrombus: a case report

BACKGROUND

Patient with α-Fetoprotein (AFP)-producing gastric cancer usually has a short survival time due to frequent hepatic and lymph node metastases. Gastric cancer with portal vein tumor thrombus (PVTT) is rare and has an extremely poor prognosis.

CASE PRESENTATION

A 63-year-old man was found to have a huge Type 3 gastric cancer with a PVTT and a highly elevated serum AFP level. Chemotherapy with S-1 plus cisplatin was given to this patient with unresectable gastric cancer for 4 months. The serum AFP level decreased from 6,160 ng/mL to 60.7 ng/mL with chemotherapy. Since the PVTT disappeared after the chemotherapy, the patient underwent total gastrectomy. Histological findings of the primary tumor after chemotherapy showed poorly differentiated adenocarcinoma without hepatoid cells and viable tumor cells remaining in less than 1/3 of the neoplastic area of mucosa and one lymph node. The cancerous cells were immunohistochemically stained by anti-AFP antibody. The patient has survived for 48 month without recurrence.

CONCLUSIONS

AFP-producing gastric cancer with a PVTT has an extremely poor prognosis, but long-term survival was achieved for this dismal condition by salvage surgery after chemotherapy.

Treatment of stage IV gastric cancer with induction chemotherapy using S-1 and cisplatin followed by curative resection in selected patients

Background

The standard treatment for stage IV gastric cancer is chemotherapy, but outcomes remain poor. The effectiveness of induction chemotherapy followed by surgery in selected patients who had a good response to chemotherapy is unclear.

Methods

A total of 59 patients with stage IV gastric cancer received induction chemotherapy with S-1 and cisplatin. In each cycle, oral S-1 (80 mg/m²) was administered for 3 weeks, followed by a 2-week drug holiday. Intravenous cisplatin (60 mg/m²) was administered on day 8 after adequate premedication and hydration. If unresectable features resolved after chemotherapy, patients underwent curative (R0) resection. The safety and outcomes of this treatment combination were evaluated, and predictive factors for survival were determined.

Results

Thirteen of 59 patients (22%) were eligible for R0 resection after induction chemotherapy. Kaplan-Meier analysis showed an overall median survival time of 13 months and a 3-year survival rate of 18.2%. Among patients who underwent R0 resection, the median survival time was 53 months and the 3-year survival rate was 53.8%. Multivariate analyses showed that negative para-aortic lymph nodes and undergoing R0 resection were independent predictors of survival.

Conclusions

Treatment of stage IV gastric cancer with S-1 and cisplatin induction chemotherapy followed by R0 resection is safe and may improve survival compared with chemotherapy alone. Further study of this dual-modality therapy is warranted.

Randomized trial on adjuvant treatment with FOLFIRI followed by docetaxel and cisplatin versus 5-fluorouracil and folinic acid for radically resected gastric cancer

BACKGROUND

Some trial have demonstrated a benefit of adjuvant fluoropirimidine with or without platinum compounds compared with surgery alone. ITACA-S study was designed to evaluate whether a sequential treatment of FOLFIRI [irinotecan plus 5-fluorouracil/folinic acid (5-FU/LV)] followed by docetaxel plus cisplatin improves disease-free survival in comparison with 5-FU/LV in patients with radically resected gastric cancer.

PATIENTS AND METHODS

Patients with resectable adenocarcinoma of the stomach or gastroesophageal junction were randomly assigned to either FOLFIRI (irinotecan 180 mg/m(2) day 1, LV 100 mg/m(2) as 2 h infusion and 5-FU 400 mg/m(2) as bolus, days 1 and 2 followed by 600 mg/m(2)/day as 22 h continuous infusion, q14 for four cycles) followed by docetaxel 75 mg/m(2) day 1, cisplatin 75 mg/m(2) day 1, q21 for three cycles (sequential arm) or De Gramont regimen (5-FU/LV arm).

RESULTS

From February 2005 to August 2009, 1106 patients were enrolled, and 1100 included in the analysis: 562 in the sequential arm and 538 in the 5-FU/LV arm. With a median follow-up of 57.4 months, 581 patients recurred or died (297 sequential arm and 284 5-FU/LV arm), and 483 died (243 and 240, respectively). No statistically significant difference was detected for both disease-free [hazard ratio (HR) 1.00; 95% confidence interval (CI): 0.85-1.17; P = 0.974] and overall survival (OS) (HR 0.98; 95% CI: 0.82-1.18; P = 0.865). Five-year disease-free and OS rates were 44.6% and 44.6%, 51.0% and 50.6% in the sequential and 5-FU/LV arm, respectively.

CONCLUSIONS

A more intensive regimen failed to show any benefit in disease-free and OS versus monotherapy.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01640782.

Neoadjuvant chemotherapy followed by surgery versus surgery alone for gastric carcinoma: systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The effect of neoadjuvant chemotherapy (NAC) on Gastric carcinoma (GC) has been extensively studied, while its survival and surgical benefits remain controversial. This study aims to perform a meta-analysis of high-quality randomized controlled trials (RCTs), comparing efficacy, safety and other outcomes of NAC followed by surgery with surgery alone (SA) for GC.

METHODS

We systematically searched databases of MEDLINE, EMBASE, The Cochrane Library and Springer for RCTs comparing NAC with SA when treating GC. Reference lists of relevant articles and reviews, conference proceedings and ongoing trial databases were also searched. Primary outcomes were 3-year and 5-year survival rates, survival time, and total and perioperative mortalities. Secondary outcomes included down-staging effects, R0 resection rate, and postoperative complications. Meta-analysis was conducted where possible comparing items using relative risks (RRs) and weighted mean differences (WMDs) according to type of data. NAC-related objective response, safety and toxicity were also specifically analyzed.

RESULTS

A total of 9 RCTs comparing NAC (n = 511) with SA (n = 545) published from 1995 to 2010 were identified. SA tended to be accompanied with higher overall mortality rate than NAC (46.03% vs 40.61%, RR: 0.83, 95% CI: 0.65-1.06, P = 0.14). Significantly, higher incidence of cases without regional lymph node metastasis observed upon resection were achieved among patients receiving NAC than those undergoing SA (25.68% vs 16.95%, RR: 1.92, 95% CI: 1.20-3.06, P = 0.006). All other parameters were comparable. Of the evaluable patients, 43.0% demonstrated either complete or partial response. The comprehensive NAC-related side-effect rate was 18.2% among patients available for safety assessment.

CONCLUSIONS

NAC contributes to lowering nodal stages, and potentially reduces overall mortality. Response rate may be an important influential factor impacting advantages, with chemotherapy-related adverse effects as a drawback. This level 1a evidence doesn't support NAC to outweigh SA in terms of survival and surgical benefits when dealing with GC.

Neoadjuvant chemotherapy followed by surgery versus surgery alone for gastric carcinoma: systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The effect of neoadjuvant chemotherapy (NAC) on Gastric carcinoma (GC) has been extensively studied, while its survival and surgical benefits remain controversial. This study aims to perform a meta-analysis of high-quality randomized controlled trials (RCTs), comparing efficacy, safety and other outcomes of NAC followed by surgery with surgery alone (SA) for GC.

METHODS

We systematically searched databases of MEDLINE, EMBASE, The Cochrane Library and Springer for RCTs comparing NAC with SA when treating GC. Reference lists of relevant articles and reviews, conference proceedings and ongoing trial databases were also searched. Primary outcomes were 3-year and 5-year survival rates, survival time, and total and perioperative mortalities. Secondary outcomes included down-staging effects, R0 resection rate, and postoperative complications. Meta-analysis was conducted where possible comparing items using relative risks (RRs) and weighted mean differences (WMDs) according to type of data. NAC-related objective response, safety and toxicity were also specifically analyzed.

RESULTS

A total of 9 RCTs comparing NAC (n = 511) with SA (n = 545) published from 1995 to 2010 were identified. SA tended to be accompanied with higher overall mortality rate than NAC (46.03% vs 40.61%, RR: 0.83, 95% CI: 0.65-1.06, P = 0.14). Significantly, higher incidence of cases without regional lymph node metastasis observed upon resection were achieved among patients receiving NAC than those undergoing SA (25.68% vs 16.95%, RR: 1.92, 95% CI: 1.20-3.06, P = 0.006). All other parameters were comparable. Of the evaluable patients, 43.0% demonstrated either complete or partial response. The comprehensive NAC-related side-effect rate was 18.2% among patients available for safety assessment.

CONCLUSIONS

NAC contributes to lowering nodal stages, and potentially reduces overall mortality. Response rate may be an important influential factor impacting advantages, with chemotherapy-related adverse effects as a drawback. This level 1a evidence doesn't support NAC to outweigh SA in terms of survival and surgical benefits when dealing with GC.

Management of gastric cancer in Asia: resource-stratified guidelines

Gastric cancer is the fourth most common cancer globally, and is the second most common cause of death from cancer worldwide. About three-quarters of newly diagnosed cases in 2008 were from Asian countries. With a high mortality-to-incidence ratio, management of gastric cancer is challenging. We discuss evidence for optimum management of gastric cancer in aspects of screening and early detection, diagnosis, and staging; endoscopic and surgical intervention; and the concepts of perioperative, postoperative, and palliative chemotherapy and use of molecularly targeted therapy. Recommendations are formulated on the basis of the framework provided by the Breast Health Global Initiative, using the categories of basic, limited, enhanced, and maximum level. We aim to provide a stepwise strategy for management of gastric cancer applicable to different levels of health-care resources in Asian countries.

Induction of a pathological complete response by four courses of neoadjuvant chemotherapy for gastric cancer: early results of the randomized phase II COMPASS trial

BACKGROUND

The prognosis for stage 3 gastric cancer is not satisfactory, even with S-1 adjuvant chemotherapy. A randomized phase II trial was conducted to compare two and four courses of neoadjuvant S-1/cisplatin (SC) and paclitaxel/cisplatin (PC) using a two-by-two factorial design for locally advanced gastric cancer. The primary endpoint was overall survival. We clarified the impact of these regimens on the secondary endpoints, including the clinical and pathological responses, chemotherapy-related toxicities, and surgical results.

METHODS

Patients received S-1 (80 mg/m(2) for 21 days with 1 week's rest)/cisplatin (60 mg/m(2) at day 8) or paclitaxel/cisplatin (80 and 25 mg/m(2), respectively, on days 1, 8, and 15 with 1 week's rest) as neoadjuvant chemotherapy.

RESULTS

Eighty-three patients were assigned to arm A (two courses of SC, n = 21), arm B (four courses of SC, n = 20), arm C (two courses of PC, n = 21), and arm D (four courses of PC, n = 21). Pathological response rate was 43 % in arm A, 40 % in arm B, 29 % in arm C, and 38 % in arm D. Pathological complete response was only observed in arms B (10 %) and D (10 %). Most bone marrow toxicities, nausea, vomiting, alopecia, and fatigue were slightly higher but acceptable in arms B and D. Grade 3/4 surgical morbidities were not commonly observed in all four arms.

CONCLUSIONS

Pathological complete response could be induced by four courses of neoadjuvant chemotherapy without a marked increase of toxicities, regardless of a SC or PC regimen.

Effectiveness of 5-flurouracil-based neoadjuvant chemotherapy in locally-advanced gastric/gastroesophageal cancer: A meta-analysis

AIM: To investigate the effectiveness of 5-flurouracil-based neoadjuvant chemotherapy (NAC) for gastroesophageal and gastric cancer by meta-analysis.

METHODS: MEDLINE and manual searches were performed to identify all published randomized controlled trials (RCTs) investigating the efficacy of the flurouracil-based NAC for gastroesophageal and gastric cancer, and RCTs of NAC for advanced gastroesophageal and gastric cancer vs no therapy before surgery. Studies that included patients with metastases at enrollment were excluded. Primary endpoint was the odds ratio (OR) for improving overall survival rate of patients with gastroesophageal and gastric cancer. Secondary endpoints were the OR of efficiency for down-staging tumor and increasing R0 resection in patients with gastroesophageal and gastric cancer. Safety analyses were also performed. The OR was the principal measurement of effect, which was calculated as the treatment group (NAC plus surgery) vs control group (surgery alone) and was presented as a point estimate with 95% confidence intervals (CI). All calculations and statistical tests were performed using RevMan 5.1 software.

RESULTS: Seven RCTs were included for the analysis. A total of 1249 patients with advanced gastroesophageal and gastric cancer enrolled in the seven trials were divided into treatment group (n = 620) and control group (n = 629). The quality scores of the RCTs were assessed according to the method of Jadad. The RCT quality scores ranged from 2 to 7 (5-point scale), with a mean of 3.75. The median follow-up time in these studies was over 3 years. The meta-analysis showed that NAC improved the overall survival rate (OR 1.40, 95%CI 1.11-1.76; P = 0.005), which was statistically significant. The 3-year progression-free survival rate was significantly higher in treatment group than in control group (37.7% vs 27.3%) (OR 1.62, 95%CI 1.21-2.15; P = 0.001). The tumor down-stage rate was higher in treatment group than in control group (55.76% vs 41.38%) (OR 1.77, 95%CI 1.27-2.49; P = 0.0009) and the R0 resection rate of the gastroesophageal and gastric cancer was higher in treatment group than in control group (75.11% vs 68.56%) (OR 1.38, 95%CI 1.03-1.85; P = 0.03), with significant differences. No obvious safety concerns about mortality and complications were raised in these trials. There were no statistically significant differences in perioperative mortality (5.08% vs 4.86%) (OR 1.05, 95%CI 0.57-1.94; P = 0.87 fixed-effect model) and in the complication rate between the two groups (13.25% vs 9.66%) (OR 1.40, 95%CI 0.91-2.14; P = 0.12 fixed-effect model). Trials showed that patients from Western countries favored NAC compared with those from Asian countries (OR 1.40, 95%CI 1.07-1.83). Monotherapy was inferior to multiple chemotherapy (OR 1.40, 95%CI 1.07-1.83). Intravenous administration of NAC was more advantageous than oral route (OR 1.41, 95%CI 1.09-1.81).

CONCLUSION: Flurouracil-based NAC can safely improve overall survival rate of patients with gastroesophageal/gastric cancer. Additionally, NAC can down the tumor stage and improve R0 resection.