Prognostic factors and recurrence pattern in node-negative advanced gastric cancer.Eur J Surg Oncol. 2013;39:136-140. [PMID: 23148932 DOI: 10.1016/j.ejso.2012.10.008]

The short- and long-term outcomes of laparoscopic D2 lymphadenectomy plus complete mesogastrium excision for lymph node-negative gastric cancer

BACKGROUND

Patients with T1-3N0M0 gastric cancer (GC) who undergo radical gastrectomy maintain a high recurrence rate. The free cancer cells in the mesogastric adipose connective tissue (Metastasis V) maybe the reason for recurrence in these individuals. We aimed to evaluate whether D2 lymphadenectomy plus complete mesogastrium excision (D2 + CME) was superior to D2 lymphadenectomy with regard to safety and oncological efficacy for T1-3N0M0 GC.

METHODS

Patients with T1-3N0M0 GC who underwent radical resection from January 2014 to July 2018 were retrospectively analyzed; there were 323 patients, of whom 185 were in the D2 + CME group and 138 in the D2 group. The primary endpoint was 5-year disease-free survival (DFS). Secondary endpoints include the 5-year overall survival (OS), recurrence pattern, morbidity, mortality, and surgical outcomes.

RESULTS

D2 + CME was associated with less intraoperative bleeding loss, a greater number of lymph nodes harvested, and less time to first postoperative flatus, but the postoperative morbidity was similar. The 5-year DFS was 95.6% (95% CI 92.7-98.5%) and 90.4% (95% CI 85.5-95.3%) in the D2 + CME group and the D2 group, respectively, with a hazard ratio (HR) of 0.455 (95% CI 0.188-1.097; p = 0.071). In terms of recurrence patterns, local recurrence was more prone to occur in the D2 group (p = 0.031). Subgroup analysis indicated that for patients with T1b-3N0M0 GC, the 5-year DFS in the D2 + CME group was considerably greater than that in the D2 group (95.3% [95% CI 91.6-99.0%] vs. 87.6% [95% CI 80.7-94.5%], HR 0.369, 95% CI 0.138-0.983; log-rank p = 0.043).

CONCLUSION

Laparoscopic D2 + CME for T1-3N0M0 GC is safe and feasible. Furthermore, it not only reduces the local recurrence rate but also improves the 5-year DFS in cases of T1b-3N0M0 GC.

Extracellular volume fraction determined by equilibrium contrast-enhanced computed tomography: correlation with histopathological findings in gastric cancer

PURPOSE

To assess the relationship between histopathological features of gastric cancer and the extracellular volume fraction (ECV) measured by preoperative equilibrium contrast-enhanced computed tomography (CECT).

MATERIALS AND METHODS

The study group consisted of 66 patients with surgically resected gastric adenocarcinoma who underwent preoperative multiphasic CECT. Tumor ECVs were calculated using region-of-interest measurements within the gastric cancer and aorta of each case on unenhanced and equilibrium-phase images. The relationship between the mean ECV values and clinicopathological parameters was examined by univariate analysis. Parameters showing a significant difference in the former test were further tested by linear regression and receiver operating characteristic (ROC) curve analyses.

RESULTS

In the univariate analysis, the values of venous invasion (p = 0.0487) and tumor infiltration (INF) pattern (p < 0.0001) were significantly correlated with the tumor ECV. INF was significantly correlated (β = 0.57, p < 0.0001) in the linear regression analysis. The tumor ECV showed better diagnostic accuracy for predicting INF (INFa/b vs INFc), and the area under the ROC curve value was 0.89.

CONCLUSION

Tumor ECV determined by equilibrium CECT is significantly correlated with the pathological INF of gastric cancer.

Prognostic Factors and the Role of Adjuvant Chemotherapy in Pathological Node-Negative T3 Gastric Cancer

The role of adjuvant chemotherapy in pathological T3N0M0 (pT3N0M0) gastric cancer (GC) remains unclear. The aim of this study was to analyze the prognostic factors of patients with pT3N0M0 GC and to clarify which ones could benefit from adjuvant chemotherapy. A total of 137 patients with pT3N0M0 GC were recruited between 1994 and 2020. Clinicopathological factors and adjuvant chemotherapy regimens were retrospectively collected. Prognostic factors of disease-free survival (DFS) and cancer-specific survival (CSS) were determined using univariate and multivariate analyses. The chemotherapy group was younger (p = 0.012), had had more lymph nodes retrieved (p = 0.042) and had higher percentages of vascular invasion (p = 0.021) or perineural invasion (p = 0.030) than the non-chemotherapy group. There were no significant differences in DFS (p = 0.222) and CSS (p = 0.126) between patients treated with or without adjuvant chemotherapy. Stump cancer, tumor size and perineural invasion were associated with higher rates of recurrence. Tumor size was an independent prognostic factor for DFS (hazard ratio, 4.55; confidence interval, 1.59-12.99; p = 0.005) and CSS (hazard ratio, 3.97; confidence interval, 1.38-11.43; p = 0.011). Tumor size independently influenced survival outcomes in pT3N0M0 patients who underwent radical surgery with and without adjuvant chemotherapy.

Diagnosis of Serosal Invasion in Gastric Adenocarcinoma by Dual-Energy CT Radiomics: Focusing on Localized Gastric Wall and Peritumoral Radiomics Features

Objectives

To build a radiomics model and combined model based on dual-energy CT (DECT) for diagnosing serosal invasion in gastric adenocarcinoma.

Materials and methods

231 gastric adenocarcinoma patients were enrolled and randomly divided into a training (n = 132), testing (n = 58), and independent validation (n = 41) cohort. Radiomics features were extracted from the rectangular ROI of the 120-kV equivalent mixed images and iodine map (IM) images in the venous phase of DECT, which was manually delineated perpendicularly to the gastric wall in the deepest location of tumor infiltration, including the peritumoral adipose tissue within 5 mm outside the serosa. The random forest algorithm was used for radiomics model construction. Traditional features were collected by two radiologists. Univariate and multivariate logistic regression was used to construct the clinical model and combined model. The diagnostic efficacy of the models was evaluated using ROC curve analysis and compared using the Delong's test. The calibration curves were used to evaluate the calibration performance of the combined model.

Results

Both the radiomics model and combined model showed high efficacy in diagnosing serosal invasion in the training, testing and independent validation cohort, with AUC of 0.90, 0.90, and 0.85 for radiomics model; 0.93, 0.93, and 0.89 for combined model. The combined model outperformed the clinical model (AUC: 0.76, 0.76 and 0.81).

Conclusion

The radiomics model and combined model constructed based on tumoral and peritumoral radiomics features derived from DECT showed high diagnostic efficacy for serosal invasion in gastric adenocarcinoma.

Incidence, Risk Factors and Prognosis of T4a Gastric Cancer: A Population-Based Study

Background: T4a gastric cancer (GC) is a subtype of advanced GC (AGC), which urgently needs a comprehensive grade method for better treatment strategy choosing. The purpose of this study was to develop two nomograms for predicting the prognosis of patients with T4a GC.

Methods: A total of 1,129 patients diagnosed as T4a GC between 2010 and 2015 were extracted from the Surveillance, Epidemiology, and End Result (SEER) program database. Univariate and multivariate Cox analyses were performed to explore the independent predictors and to establish nomogram for overall survival (OS) of the patients, whereas competing risk analyses were performed to find the independent predictors and to establish nomogram for cancer-specific survival (CSS) of the patients. The area under the curve (AUC), calibration curve, decision curve analysis (DCA), and Kaplan–Meier analysis were performed to evaluate the nomograms.

Results: Older age, larger tumor size, black race, signet ring cell carcinoma (SRCC), more lymph node involvement, the absence of surgery, the absence of radiotherapy, and the absence of chemotherapy were identified as independent prognostic factors for both OS and CSS. In the training cohort, the AUCs of the OS nomogram were 0.760, 0.743, and 0.723 for 1-, 3-, and 5-year OS, whereas the AUCs of the CSS nomogram were 0.724, 0.703, and 0.713 for 1-, 3-, and 5-year CSS, respectively. The calibration curve and DCA indicated that both nomograms can effectively predict OS and CSS, respectively. The abovementioned results were also confirmed in the validation cohort. Stratification of the patients into high- and low-risk groups highlighted the differences in prognosis between the two groups both in training and in validation cohorts.

Conclusions: Age, tumor size, race, histologic type, N stage, surgery status, radiotherapy, and chemotherapy were confirmed as independent prognostic factors for both OS and CSS in patients with T4a GC. Two nomograms based on the abovementioned variables were constructed to provide more accurate individual survival predictions for them.

Enlarged folds on endoscopic gastritis as a predictor for submucosal invasion of gastric cancers

BACKGROUND

Accurate diagnosis of the depth of gastric cancer invasion is crucial in clinical practice. The diagnosis of gastric cancer depth is often made using endoscopic characteristics of the tumor and its margins; however, evaluating invasion depth based on endoscopic background gastritis remains unclear.

AIM

To investigate predicting submucosal invasion using the endoscopy-based Kyoto classification of gastritis.

METHODS

Patients with gastric cancer detected on esophagogastroduodenoscopy at Toyoshima Endoscopy Clinic were enrolled. We analyzed the effects of patient and tumor characteristics, including age, sex, body mass index, surveillance endoscopy within 2 years, current Helicobacter pylori infection, the Kyoto classification, and Lauren's tumor type, on submucosal tumor invasion and curative endoscopic resection. The Kyoto classification included atrophy, intestinal metaplasia, enlarged folds, nodularity, and diffuse redness. Atrophy was characterized by non-reddish and low mucosa. Intestinal metaplasia was detected as patchy whitish or grayish-white flat elevations, forming an irregular uneven surface. An enlarged fold referred to a fold width ≥ 5 mm in the greater curvature of the corpus. Nodularity was characterized by goosebump-like multiple nodules in the antrum. Diffuse redness was characterized by uniform reddish non-atrophic mucosa in the greater curvature of the corpus.

RESULTS

A total of 266 gastric cancer patients (mean age, 66.7 years; male sex, 58.6%; mean body mass index, 22.8 kg/m2) were enrolled. Ninety-three patients underwent esophagogastroduodenoscopy for surveillance within 2 years, and 140 had current Helicobacter pylori infection. The mean Kyoto score was 4.54. Fifty-eight cancers were diffuse-type, and 87 cancers had invaded the submucosa. Multivariate analysis revealed that low body mass index (odds ratio 0.88, P = 0.02), no surveillance esophagogastroduodenoscopy within 2 years (odds ratio 0.15, P < 0.001), endoscopic enlarged folds of gastritis (odds ratio 3.39, P = 0.001), and Lauren's diffuse-type (odds ratio 5.09, P < 0.001) were independently associated with submucosal invasion. Similar results were obtained with curative endoscopic resection. Among cancer patients with enlarged folds, severely enlarged folds (width ≥ 10 mm) were more related to submucosal invasion than mildly enlarged folds (width 5-9 mm, P < 0.001).

CONCLUSION

Enlarged folds of gastritis were associated with submucosal invasion. Endoscopic observation of background gastritis as well as the lesion itself may help diagnose the depth of cancer invasion.

RECURRENCE IN PN0 GASTRIC CANCER: RISK FACTORS IN THE OCCIDENT

BACKGROUND

Nearly 10% of node negative gastric cancer patients who underwent curative surgery have disease recurrence. Western data is extremely poor on this matter and identifying the risk factors that associate with relapse may allow new strategies to improve survival.

AIM

Verify the clinical and pathological characteristics that correlate with recurrence in node negative gastric cancer.

METHODS

All gastric cancer patients submitted to gastrectomy between 2009 and 2019 at our institution and pathologically classified as N0 were considered. Their data were available in a prospective database. Inclusion criteria were: gastric adenocarcinoma, node negative, gastrectomy with curative intent, R0 resection. Main outcomes studied were: disease-free survival and overall survival.

RESULTS

A total of 270 patients fulfilled the inclusion criteria. Mean age was 63-year-old and 155 were males. Subtotal gastrectomy and D2 lymphadenectomy were performed in 64% and 74.4%, respectively. Mean lymph node yield was 37.6. Early GC was present in 54.1% of the cases. Mean follow-up was 40.8 months and 19 (7%) patients relapsed. Disease-free survival and overall survival were 90.9% and 74.6%, respectively. Independent risk factors for worse disease-free survival were: total gastrectomy, lesion size ≥3.4 cm, higher pT status and <16 lymph nodes resected.

CONCLUSION

In western gastric cancer pN0 patients submitted to gastrectomy, lymph node count <16, pT3-4 status, tumor size ≥3.4 cm, total gastrectomy and presence of lymphatic invasion, are all risk factors for disease relapse.

Determinants of Survival for Patients with Neoadjuvant-Treated Node-Negative Gastric Cancer

BACKGROUND

This study sought to determine prognostic markers for disease recurrence and survival in a cohort of neoadjuvant-treated, node-negative gastric cancer patients (ypT0-4N0M0).

METHODS

Clinicopathologic data from patients treated with neoadjuvant therapy followed by curative-intent gastrectomy at the University of Texas MD Anderson Cancer Center from 1995 to 2017 were evaluated. Patients with AJCC TNM stage ypT0-4N0M0 were considered for analysis.

RESULTS

The inclusion criteria were met by 212 patients with a mean age of 58.3 years. Of these patients, 60 % were male, 53 % were Caucasian, 87 % received chemoradiation, and 13 % received chemotherapy. The findings showed a median overall survival (OS) rate of 11.3 years, a 5-year survival rate of 72 %, and a 10-year survival rate of 57 %. During a median follow-up period of 5.5 years, 38.2 % of the patients died. In the multivariable analysis, ypT4-stage and nodal yield fewer than 16 were significantly associated with reduced OS. Cancer classified as ypT4 had more aggressive biologic traits, including lymphovascular and perineural invasion, and was treated more aggressively with total gastrectomy and additional organ resection despite frequent positive margins. Depth of invasion remained significantly associated with worse outcome after the analysis controlled for nodal yield and possible stage migration. Compared with ypT0-3 tumors, ypT4 cancers were associated with significantly more recurrences (13 % vs. 45 %; p < 0.05), and the primary modes of failure for ypT4 lesions were local recurrence and peritoneal metastases (88 % of recurrences).

CONCLUSIONS

Depth of primary tumor invasion and nodal yield were significantly associated with OS among the patients with ypT0-4N0M0 gastric cancer. Serosal invasion (ypT4) was associated with a high rate of peritoneal recurrence, and trials of intraperitoneal therapy targeting these patients should be considered.

Adjuvant Chemotherapy vs. Surgery Alone for pT3N0M0 Gastric Cancer

BACKGROUND

As both the role and clinical application of adjuvant chemotherapy (CTx) for pT3N0M0 gastric cancer after curative gastrectomy have fluctuated chronologically, the oncological benefit of adjuvant CTx in patients should be elucidated.

METHODS

Between 2000 and 2018, 1083 patients underwent radical gastrectomy for pT3N0M0 gastric cancer and were subsequently divided into two groups: the surgery-alone group (n = 471) and the adjuvant CTx group (n = 612). Chronological changes in adjuvant CTx and various chemotherapeutic regimens were evaluated and disease-free survival was compared between the two groups. Risk factors for tumor recurrence were also analyzed.

RESULTS

The proportion of patients in the surgery-alone group was more than 60% until 2001, whereas in the CTx group this increased to over 80%, especially after publication of the American Joint Committee on Cancer (AJCC) 7th edition staging manual. The main chemotherapeutic agents were tegafur-uracil (UFT) and 5-fluorouracil with leucovorin until 2008, whereas tegafur/gimeracil/oteracil (TS-1) has been the main agent since 2009. The 5-year disease-free survival was 89.2% in the surgery-alone group and 89.9% in the CTx group, which was not significantly different (p = 0.694). In multivariate analysis, larger tumor size (≥ 4.5 cm) and venous invasion were significant risk factors for tumor recurrence. In addition, adjuvant CTx did not improve the oncological outcome, even in the large tumor size group (p = 0.760) and the venous invasion group (p = 0.753).

CONCLUSIONS

As adjuvant CTx did not show any oncological benefit in pT3N0M0 gastric cancer in this large-scale study, it might be unnecessary for these patients after curative gastrectomy.

High Level of Legumain Was Correlated With Worse Prognosis and Peritoneal Metastasis in Gastric Cancer Patients

Background: Accumulating evidence has demonstrated that legumain (LGMN) is abnormally expressed in several malignancies and functions as an oncogene. However, the association between LGMN and gastric cancer (GC) has not yet been fully elucidated. In this study, we performed a comprehensive analysis of the role of LGMN in clinicopathologic characteristics and survival of GC patients.

Methods: The study had two patient cohorts, The Cancer Genome Atlas (TCGA) cohort and the Zhongshan Hospital cohort, both of which were used to analyze the role of LGMN in GC samples. The relationship between LGMN and clinicopathologic characteristics was determined by the Chi-square test and logistic regression analysis. The Kaplan–Meier method and Cox proportional hazards regression analysis were conducted to investigate the prognostic role of LGMN in GC patients. Moreover, a nomogram was constructed based on the factors that were independently associated with peritoneal metastasis. Finally, the gene set enrichment analysis (GSEA) was conducted to explore the underlying pathways through which LGMN was involved in GC progression.

Results: The mRNA and protein levels of LGMN were significantly upregulated in GC tissues, especially for diffuse-type GC. High level of LGMN was independently associated with poor prognosis in both TCGA and Zhongshan cohorts. Further analysis showed that increased protein level of LGMN was related to peritoneal metastasis in GC patients. In a nomogram model, the LGMN expression could help predict the possibility of peritoneal metastasis in GC patients. LGMN was a strong determinant for prediction of peritoneal metastasis. GC patients with high LGMN expression tended to have worse survival together with more frequent diffuse-type tumors and increased risk of peritoneal metastasis. The GSEA results showed that focal adhesion, ecm receptor interaction, cell adhesion molecules cams, TGF-β signaling pathway, JAK-STAT signaling pathway, gap junction, etc. were differentially enriched in the phenotype with high LGMN expression.

Conclusion: LGMN was an independent prognostic factor for OS in GC patients. Increased expression of LGMN was significantly associated with peritoneal metastasis. The nomogram based on LGMN might guide the clinical decisions for patients with GC.

Clinicopathologic factors associated with recurrence and long-term survival in node-negative advanced gastric cancer patients

BACKGROUND

despite a better prognosis in node-negative advanced gastric cancer (GC), a proportion of patients have a tumor recurrence within five years and eventually die due to cancer-related causes. The present study aimed to evaluate the predictive factors of tumor recurrence and long-term survival in node-negative advanced GC.

METHODS

a total of 646 node-negative advanced GC patients who underwent a curative gastrectomy in our institution were included in the study. The impact of different clinicopathologic factors on tumor recurrence and overall survival were analyzed.

RESULTS

tumor recurrences were observed in 181 patients and the cumulative recurrence rate at two-years and five-years were 50.8% and 86.2%, respectively. Lymphovascular invasion, advanced T stage (T3-T4) and an inadequate number of retrieved lymph nodes (LNs) were independent predictive factors of tumor recurrence in node-negative advanced GC. Older age, an upper 1/3 tumor, lymphovascular invasion, infiltration growth pattern (INFγ) and the depth of tumor invasion (T4 stage) were independently associated with long-term survival. With regard to node-negative patients with ≥ 15 retrieved LNs, infiltration growth pattern (INFγ) and advanced T stage (T3-T4) were independent risk factors for both tumor recurrence and long-term survival.

CONCLUSION

in addition to lymphovascular invasion, inadequate RLNs and advanced T stage, the prognostic significance of infiltration growth pattern in node-negative advanced GC was especially emphasized. These risk factors should be considered when selecting candidates for adjuvant chemotherapy and postoperative surveillance.

Prognostic impact of extranodal extension in stage 1B gastric carcinomas

BACKGROUND

In addition to the TNM stage, an additional prognostic factor is needed to assess the prognosis of gastric cancer. Moreover, there is no consensus on high-risk group of recurrence and adjuvant strategy in stage 1B gastric cancers. We aimed to investigate the prognostic significance of extranodal extension (ENE) in stage 1B gastric carcinomas and assess whether ENE can indicate the need for adjuvant treatment.

METHODS

The clinicopathological characteristics of 1588 patients who underwent curative gastrectomy with more than D1 plus lymphadenectomy for stage 1B gastric cancer from 2003 to 2010 were reviewed. A propensity score matching analysis was performed.

RESULTS

Age over 65 years and the presence of ENE were found to be poor prognostic factors for both overall survival (OS) and disease-free survival (DFS). Adjuvant chemotherapy was related to an increased overall survival. The 5 year OS and DFS rates were 88.7% and 86.2%, respectively. When divided into 3 groups (early gastric cancer with ENE [T1N1 ENE(+)], early cancer without ENE [T1N1 ENE(-)], and advanced tumor without nodal metastasis [T2N0]), the OS and DFS rates of the T1N1 ENE(+) group were significantly worse than those of the other groups (5 year OS rate of 72.7% vs. 88.4% vs. 91.9%, respectively, P < 0.001 and 5 year DFS rate of 67.2% vs. 85.2% vs. 91.5%, respectively, P < 0.001).

CONCLUSION

ENE is an independent prognostic factor that predicted poor outcomes for stage 1B gastric cancers and it could be an indicator of the need for adjuvant treatment.

miR-126: An indicator of poor prognosis and recurrence in histologically lymph node-negative gastric cancer

BACKGROUND

Few biomarkers are available for the prediction of prognosis and recurrence in lymph node (LN)-negative gastric cancer (GC) currently. miR-126 functions as a tumor suppressor in GC, however, its clinical significance in LN-negative GC remains unknown.

AIM

To investigate the associations of tissue miR-126 level with the clinicopathological characteristics and clinical outcome of LN-negative GC patients.

METHODS

Quantitative real-time polymerase chain reaction was performed to examine the tissue miR-126 level in 315 LN-negative GC patients who underwent curative gastrectomy with D2 lymphadenectomy. The associations of tissue miR-126 level with clinicopathological characteristics and clinical outcome were evaluated.

RESULTS

Compared with matched adjacent non-tumor tissues, miR-126 expression was significantly down-regulated in tumor tissues. A reduced tissue miR-126 level statistically correlated with aggressive clinicopathological characteristics, including larger tumor size, deeper local invasion, and poorer prognosis. Notably, multivariate analysis identified advanced T stage and low miR-126 level as independent predictors of the unfavorable prognosis and recurrence of LN-negative GC.

CONCLUSIONS

These results indicate for the first time that advanced T stage and low miR-126 level are predictors of unfavorable prognosis and recurrence in LN-negative GC patients. These parameters should be taken into account to stratify patients for adjuvant therapy and close follow-up.

Clinical Implication of the Width of Subserosal Invasion in T3N0 Gastric Cancer

BACKGROUND

The aim of this study was to clarify the impact of the horizontal width of tumor invasion into the subserosal layer on prognosis in patients with T3N0 gastric cancer.

PATIENTS AND METHODS

A total of 72 patients with T3N0 cancer were enrolled. Relapse-free survival of the subgroups classified according to width of subserosal invasion was compared to that of 34 patients with T4aN0 cancer.

RESULTS

The group with wide invasion (≥1.5 cm) had a significantly poorer prognosis than those with narrow invasion (<1.5 cm) (p=0.014). Multivariate analysis revealed the width of subserosal invasion to be an independent prognostic factor. There was no significant difference between the T3N0 group with wide invasion and the T4aN0 group in the prognosis and recurrent status.

CONCLUSION

The malignant potential of T3N0 gastric cancer with wide subserosal invasion was found to be similar to that of T4aN0 cancer.

Influence of perineural invasion in predicting overall survival and disease-free survival in patients With locally advanced gastric cancer

BACKGROUND

The aim of the present study was to evaluate the prognostic significance of perineural invasion (PNI) in locally advanced gastric cancer patients who underwent D2 gastrectomy and adjuvant chemotherapy.

METHODS

The records of a series of 103 patients undergoing D2 gastrectomy with curative intent combined with adjuvant chemotherapy from January 2004 to December 2014 were retrospectively reviewed.

RESULTS

PNI was positive in 47 (45.6%) specimens. The 1-, 3-, and 5-year overall survival rates were 81%, 55%, and 42%, respectively. The 1-, 3-, and 5-year disease-free survival (DFS) rates were 76%, 57%, and 49%, respectively. A multivariate analysis showed that age number of positive lymph nodes, T stage, and PNI were independently associated with overall survival. Regarding DFS, the multivariate analysis showed that only PNI was independently associated with DFS.

CONCLUSIONS

PNI and T stage and positive lymph nodes are independent markers of poor prognosis in patients with gastric cancer. PNI should be incorporated in the postoperative staging system for planning follow-up after surgery and in our opinion to propose more aggressive postoperative therapies in PNI-positive patients.

Is There Any Role of Adjuvant Chemotherapy for T3N0M0 or T1N2M0 Gastric Cancer Patients in Stage II in the 7th TNM but Stage I in the 6th TNM System?

BACKGROUND

Controversy surrounds adjuvant chemotherapy (CTx) for T3N0M0 and T1N2M0 in the American Joint Committee on Cancer (AJCC) 7th edition stage IIA gastric cancer patients. The purpose of this study was to evaluate the benefit of adjuvant CTx for stage IIA cancer, including T3N0M0 and T1N2M0.

METHODS

A total of 630 patients with stage IIA cancer who underwent a radical gastrectomy between January 1999 and December 2009 at Seoul National University Hospital were retrospectively analyzed. We compared the outcomes of 434 patients who did not receive CTx (the non-CTx group) with those of 196 patients who received CTx comprising of 5-fluorouracil-based regimens (the CTx group).

RESULTS

The 5-year overall survival (OS) rates of the non-CTx and CTx groups were 86.4 and 89.3 %, respectively (p = 0.047). In the subgroup analysis of T2N1M0 (6th II/7th IIA), there was a significant difference in OS between the non-CTx and CTx groups (p = 0.003), but no differences were observed in T3N0M0 and T1N2M0 (6th IB/7th IIA) (p = 0.574 and p = 0.934). The multivariate analysis showed that a tumor size greater than 5 cm in T3N0M0 [odds ratio (OR) 1.929; p = 0.030], no adjuvant CTx in T2N1M0 (OR 4.853; p = 0.025), and no factors in T1N2M0 were found to be risk factors for recurrence-free survival.

CONCLUSIONS

Adjuvant CTx may be associated with an improved outcome of patients with T2N1M0 (6th II/7th IIA), but not T3N0M0 or T1N2M0 (6th IB/7th IIA), gastric cancer. To confirm these results, further studies are needed.

Prognostic significance of lymphovascular invasion in node-negative gastric cancer

BACKGROUND

The aim of this study was to investigate the prognostic value of lymphovascular invasion (LVI) in gastric cancer patients without lymph node metastasis.

METHODS

A total of 699 patients with primary tumor pT1-3/pN0-1 gastric adenocarcinoma who underwent curative resection from 2001 to 2010 were categorized into 3 groups: One-hundred and eleven patients with pN0/LVI(+), 475 with pN0/LVI(-), and 103 with pN1.

RESULTS

The tumors in patients with N0/LVI(+) had more aggressive clinicopathologic features than those in patients with N0/LVI(-). However, there was no significant difference in patient characteristics between patients with pN0/LVI(+) and those with pN1, except for histologic grade. There were no significant differences in the overall survival rate in patients with pN0/LVI(+) compared to those with pN0/LVI(-) or the pN1 stage. However, the recurrence-free survival rate of the pN0/LVI(+) group was lower than that of the pN0/LVI(-) group (p < 0.001), while no significant difference was observed between the pN0/LVI(+) and the N1 groups (p = 0.216). In multivariate analysis, LVI was identified as a poor prognostic factor related to recurrence-free survival in node-negative gastric cancer patients. pT3 stage and less than D2 lymphadenectomy were poor prognostic factors affecting recurrence-free survival, and less than D2 lymphadenectomy was an independent poor prognostic factor for overall survival in pN0/LVI(+) patients.

CONCLUSIONS

LVI could be an indicator of biological aggressiveness and may be a reliable prognostic factor for node-negative gastric cancer. LVI should be considered in postoperative management of gastric cancer.

Relationship Between 18F-FDG Uptake on PET and Recurrence Patterns After Curative Surgical Resection in Patients with Advanced Gastric Cancer

This study evaluated the predictive value of 18F-FDG PET for distant metastasis-free survival and peritoneal recurrence-free survival as well as recurrence-free survival and overall survival after curative surgical resection in patients with advanced gastric cancer (AGC).

METHODS

Two hundred seventy-nine patients with AGC who underwent preoperative 18F-FDG PET and subsequent curative surgical resection were included. The tumor-to-normal liver uptake ratio (TLR) of cancer lesions was measured, and the prognostic significance of TLR and tumor factors for distant metastasis-free survival, peritoneal recurrence-free survival, recurrence-free survival, and overall survival was assessed.

RESULTS

The 5-y recurrence-free survival, peritoneal recurrence-free survival, distant metastasis-free survival, and overall survival rates were 46.9%, 68.5%, 76.0%, and 58.1%, respectively. Depth of tumor invasion, lymph node metastasis, lymphovascular invasion, and TLR were independent prognostic factors for both recurrence-free survival and overall survival (P<0.05). For distant metastasis-free survival, lymphovascular invasion and TLR were independent risk factors (P<0.05). In patients with a TLR of 2.0 or less, the 5-y distant metastasis-free survival rate was 95.5%; in patients with a TLR greater than 2.0, the 5-y distant metastasis-free survival rate was 68.8%. For peritoneal recurrence-free survival, TLR showed no statistical significance (P=0.7) whereas pT stage, lymph node metastasis, Lauren classification, and Bormann type were independent prognostic factors (P<0.05).

CONCLUSION

18F-FDG uptake of AGC is an independent prognostic factor for distant metastasis-free survival, recurrence-free survival, and overall survival. The possibility of distant metastasis during follow-up should be considered in patients with high 18F-FDG uptake.

Survival after Gastrectomy in Node-Negative Gastric Cancer: A Review and Meta-Analysis of Prognostic Factors

Background

Lymph node metastasis is one of the most important prognostic factors for survival of patients with gastric cancer (GC) after surgical resection. Nevertheless, a considerable number of patients have node-negative disease. We performed the present systematic review to evaluate survival and identify prognostic factors in node-negative GC patients undergoing curative intent resection.

Material/Methods

Relevant studies published between January 2000 and January 2015 were identified by searching the PubMed database and reviewed systematically. Summary relative risks (RR) and 95% confidence intervals (95% CI) were estimated using random-effects models.

Results

Thirty observational studies involving 12 504 patients were included in the review. Median 5-year overall survival was 84.3% (range, 53–96.3%). Pooled analysis showed that old age (RR, 1.26; 95%CI, 1.13–1.42), <D2 lymph node dissection (1.28; 1.05–1.55), larger tumor (1.18; 1.10–1.26), serosal invasion (2.03; 1.68–2.44), lymphatic invasion (1.25; 1.00–1.57), vascular invasion (1.67; 1.19–2.34), and lymphovascular invasion (1.93; 1.20–3.10) were significant association with decreased survival.

Conclusions

Surgical resection offers good overall survival for patients with node-negative GC. Tumor-related factors seem to have most prognostic significance.

Impact on survival of the number of lymph nodes resected in patients with lymph node-negative gastric cancer

Background

Patients with lymph node-negative gastric cancer show a better overall survival rate than those who have a pathological lymph node-positive gastric cancer. But a large number of patients still develop recurrence. We aimed to explore the significant prognostic factors of lymph node-negative gastric cancer and determine how many lymph nodes should be removed.

Methods

A total of 3103 patients who underwent radical operation are identified from the Surveillance, Epidemiology, and End Results database. Standard survival methods and restricted multivariable Cox regression models were applied.

Results

The overall survival rate was significantly higher with an increasing number of negative lymph node resected. Among the 843 patients who had the exact T stage, the overall survival rate was significantly better in T3-4 group with more than 15 lymph nodes resected (P < 0.001) but not in T1-2 stage patients (P = 0.44). A further 25 more lymph nodes resection did not show additional survival benefits. Multivariate analysis of patients demonstrated that age, depth of tumor invasion, and the number of lymph nodes resected were the significant and independent prognostic factors.

Conclusions

A lymphadenectomy with more than 15 lymph nodes removal should be performed for T3-4 lymph node-negative gastric cancer. But the survival benefit of a lymphadenectomy with more than 25 lymph nodes removal is disputed. And the further treatment should refer to the prognostic indicators.

Conventional clinical and pathological features fail to accurately predict recurrence in patients with gastric cancer staged N0

INTRODUCTION

Despite the medical-surgical advances, even after R0 gastric resections, some patients without apparent metastatic disease develop cancer recurrence and eventually die.

AIMS

We aimed to define recurrence in patients with node-negative gastric adenocarcinoma and to determine whether any clinicopathological features are predictive for recurrence.

MATERIALS AND METHODS

This was a retrospective cohort study on patients with gastric adenocarcinoma, consecutively diagnosed at our institution, staged as N0M0 between January 2000 and December 2008.

RESULTS

We recruited 129 patients; 53% were men and 56% were older than 60 years. A total of 22% of the patients developed recurrence, with a mortality rate of 93%. Overall, 71% of the patients, N0, with recurrence presented lymphatic permeation. In univariate analysis, on comparing recurrent patients with those with no recurrence, age, size, T status, lymphatic, and venous permeation were factors that were associated significantly with recurrence, but in multivariate analysis, only age (odds ratio:19.5; 95% confidence interval: 2.3-168; P=0.008) and venous permeation (odds ratio: 6.34; 95% confidence interval: 1.8-22.8; P=0.005) were associated with recurrence. On the basis of only these two factors, the proportion of missed recurrent patients by age and venous permeation was 13 and 39%, respectively.

CONCLUSION

A total of 22% of patients, N0, developed recurrence of their disease. Age and venous permeation were independent risk factors for recurrence, but on the basis of these factors, up to 40% of patients may be missed for recurrence. New methods to predict recurrence are needed.

Upper lesser curvature skeletonization in radical distal gastrectomy

BACKGROUND

To investigate the metastatic status of lymph nodes numbers (no.) 1, 3a, and 3b groups in radical distal gastrectomy with upper lesser curvature skeletonization and the risk factors for lesser curvature regional node (LCRN) metastasis.

METHODS

Data on patients who underwent radical distal gastrectomy were retrospectively collected between May 2010 and September 2013. Clinicopathologic features and surgical outcomes were compared between the LCRN (+) and (-) groups. The correlations among the no. 1, 3a and 3b groups, and other groups were analyzed. Univariate and multivariate analyses were performed to identify the independent risk factors for LCRN metastasis.

RESULTS

A total of 112 patients were analyzed. In all, 45.5% had metastatic LCRNs, and 59.8% were node positive overall. The LCRN (+) and (-) groups had significantly different features, including gender; tumor size; histologic grade; Lauren classification; gross type; and T, N, and TNM stages. The positivity rates of the no. 1, 3a, and 3b groups were 4.5%, 38.4%, and 32.1%, respectively, and the no. 1, 3a, and 3b groups were comprehensively correlated with the D2-tier groups. In the univariate and multivariate analyses, only stage T3-4 and positive no. 4d nodes were documented as independent risk factors, whereas no. 5 and 11p nodes trended toward a positive correlation.

CONCLUSIONS

LCRNs have high frequencies of metastasis in lower gastric cancers, and in the present study, these groups of lymph nodes tended to be associated with each other as an entity in the lesser curvature region. Upper lesser curvature skeletonization can be recommended as a standard procedure in radical distal gastrectomy to thoroughly clear the gastric stump, especially in the case of stage T3-4 or suspicious no. 4d nodes.

Predictive factors for survival and recurrence rate in patients with node-negative gastric cancer--a European single-centre experience

PURPOSE

Gastric cancer is a common disease with poor prognosis. Lymph node involvement is the strongest prognostic factor regarding survival in curatively (R0) resected patients. The aim of this study was to determine if a subgroup with higher risk for tumour recurrence exists in patients with node-negative gastric cancer. Furthermore, we aimed to identify prognostic factors and recurrence patterns for this subgroup.

METHODS

We collected demographical, clinical, pathohistological and follow-up data from 1,074 patients with gastric cancer in a prospectively maintained database. In 228 cases, R0 resections for node-negative gastric cancer were performed. The median follow-up period was 59 months. Statistical analysis was performed using SPSS 19.0.

RESULTS

The 5- , 10- and 15-year overall survival was 83, 75.5 and 73 %, respectively, with a disease-free survival of 78, 73 and 73 %. Tumour recurrence was observed in 18.9 % (43 cases), 14 % of which were diagnosed after more than 5 years. Gender, T-category , lymphangioinvasion, tumour differentiation, serosal infiltration, histological growth pattern, tumour size and classification according to Lauren were significant prognostic factors for overall survival in univariate analysis. Multivariate analysis showed tumour size and female sex to be independent prognostic factors. Non-exophytic tumour growth was a relevant factor for the development of local recurrence. Diffuse type gastric cancers as well as signet ring cells were significantly associated with the development of peritoneal carcinomatosis, and male gender with hematogenous metastases.

CONCLUSIONS

Multimodal treatment and individual follow-up might be beneficial in patients with higher risk of recurrence after R0 resection of node-negative gastric cancer.

Prognostic impact of lymph node retrieval and ratio in gastric cancer: a U.S. single center experience

INTRODUCTION

Increased lymph node (LN) retrieval for gastric cancer has been associated with improved overall survival (OS). This study examines the impact of number of examined LN (eLN) and lymph node ratio.

METHODS

Patients referred for surgical care of gastric cancer were stratified by number of eLN, positive LNs (LN+), and lymph node ratio (LN+/eLN). Clinicopathologic factors were compared; OS and disease-free survival (DFS) were the primary endpoints.

RESULTS

From 1997 to 2012, 222 patients, median age 67 (range, 17-92) years, were analyzed. Of 220 (99 %) explored, 164 (74 %) underwent resection. Median OS was 22 (range, 0.3-140) months. Perineural and lymphovascular invasion and poor differentiation adversely affected OS, p < 0.05. A median 14 eLN (range, 0-45), with median 1 LN+ (range, 0-31), was observed. There were no OS or DFS differences when comparing the eLN groups. Both OS and DFS were impacted by LN+. Lymph node ratio demonstrated worse median OS with increasing ratio: 49 months (0) to 37 months (0.01-0.2), 27 months (0.21-0.5), and 12 months (>0.5), p < 0.0001. DFS was similar: 35 months (0), decreasing to 22 months (0.01-0.2), 13 months (0.21-0.5), and 7 months (>0.5), p < 0.0001.

CONCLUSION

Number of eLN did not impact survival, while LN+ adversely affected survival. Lymph node ratio may predict prognosis better than number of eLN or LN+ in gastric cancer.