Postoperative adjuvant treatment for gastric cancer improves long-term survival after curative resection and D2 lymphadenectomy. Results from a Latin American Center

Impact of Adjuvant FOLFOX on Quality of Life and Peripheral Neuropathy Incidence in Patients With Gastric Cancer: A Prospective Cohort Study

OBJECTIVES

Perioperative and adjuvant chemotherapy have demonstrated clinical benefits in localized gastric cancer. Nevertheless, the reports on their effects on patient's health-related quality of life (HRQoL) are scarce. Here, we prospectively assessed quality of life and the incidence of chemotherapy-induced peripheral neuropathy (CIPN) in a cohort of patients treated with adjuvant FOLFOX.

METHODS

Localized stomach or gastroesophageal junction adenocarcinoma patients who underwent curative resection were recruited at a single center. All patients received adjuvant FOLFOX6, and HRQoL and CIPN were assessed using the European organization for research and treatment of cancer quality life (EORTC) C30 and the EORTC CIPN20 questionnaires, respectively. Clinically significant deterioration of HRQoL was also assessed as a coprimary outcome in a longitudinal analysis.

RESULTS

We recruited a total of 63 patients. Median age was 62.5 years, and 75% had stomach tumors. Twenty-four weeks after the start of treatment, the probability of being free from HRQoL deterioration and CIPN was 29% (95% confidence interval [CI] 18%-42%) and 6% (95% CI 2%-17%), respectively. Five-year disease-free survival was 45% (95% CI 24%-64%) and 5-year overall survival was 63% (95% CI 48%-76%).

CONCLUSIONS

Adjuvant FOLFOX is associated with a high rate of long-term survival in localized gastric cancer; nevertheless, it has detrimental effects on patients' quality of life.

Adjuvant radiochemotherapy in locally advanced gastric cancer: from evidence to daily clinical practice in a single institution

Background

Gastric cancer is one of the main important causes of cancer death in Chile.

Objective

To report the results of adjuvant radiochemotherapy in advanced gastric cancer.

Material and Methods

Between 2000 and 2018, 214 subjects aged 23-85 (median, 62) years with lymph node and/or serosa involvement were treated with adjuvant chemoradiotherapy after curative resection.

Results

With a median follow-up of 41 months, overall 3- and 5-year survival was 54.9% and 40.85%, respectively. On multivariate analysis, the factors associated with lower survival were aged >65 years, stage group and number of lymph nodes involved.

Conclusion

In patients with locoregionally advanced gastric cancer treated with curative intent with surgery and adjuvant radiochemotherapy, the overall 5-year survival reported from local clinical practice is similar to that reported in randomised series and supports its use as an effective treatment for this type of patients in our country.

Distinguish the Role of Radiotherapy From Chemoradiotherapy for Gastric Cancer With Behavior of Metastasis-Indolent in Lymph Node

BACKGROUND

Although the landmark INT-0116 trial and National Comprehensive Cancer Network (NCCN) guidelines recommended pT3-4Nx gastric cancer (GC) patients to receive chemoradiotherapy, the role of radiotherapy has not been distinguished from chemoradiotherapy.

METHODS

GC with behavior of metastasis-indolent in lymph node (MILN) being confirmed with more than 15 examined LNs after gastrectomy were identified using the Surveillance, Epidemiology and End Result (SEER) database. The cancer-specific survival (CSS) of subgroups for radiotherapy, chemotherapy, chemoradiotherapy and non-adjuvant-treatment were compared. Propensity score matching (PSM) was performed between radiotherapy and non-radiotherapy subgroups to further distinguish the role of radiotherapy from chemoradiotherapy. Cox regression was performed to identify whether radiotherapy or chemotherapy could independently improve prognosis.

RESULTS

We identified 690 MILN GC patients in SEER database. 5-year CSS was 71.9% in radiotherapy subgroup and 75.1% in non-radiotherapy subgroup(HR = 1.013, 95% CI = 0.714-1.438, p = 0.940), 75.6% in chemotherapy subgroup and 68.5% in non-chemotherapy subgroup(HR = 0.616, 95% CI = 0.430-0.884, p = 0.008), 52.5% in radiotherapy-alone subgroup and 71.9% in non-adjuvant treatment group (HR = 1.604, 95% CI = 0.575-4.471, p = 0.360), 72.9% in chemoradiotherapy subgroup and 79.5% in chemotherapy-alone subgroup (HR = 1.365, 95% CI = 0.859-2.172, p = 0.185), respectively. Further, PSM markedly improved balance of variables between radiotherapy subgroup and non-radiotherapy subgroup. After PSM, the role of the variables of radiotherapy and chemotherapy in contributing to improving CSS are consistent with that before PSM. Cox regression showed chemotherapy, tumor size, tumor invasiveness and Lauren classification were independent prognostic factors, but not including radiotherapy.

CONCLUSIONS

Chemoradiotherapy confers superior prognosis to MILN GC patients compared with surgery alone might only be attributed to chemotherapy rather than radiotherapy.

INTRODUCTION OF THE NEW LYMPHOPARIETAL INDEX FOR GASTRIC CANCER PATIENTS

Background:

The identification of prognostic factors of gastric cancer (GC) has allowed to predict the evolution of patients.

Aim:

Assess the reliability of the lymphoparietal index in the prediction of long-term survival in GC treated with curative intent.

Method:

Prospective study of the Universidad de Chile Clinical Hospital, between May 2004 and May 2012. Included all gastric cancer surgeries with curative intent. Exclusion criteria were: gastrectomies due to benign lesions, stage 4 cancers, R1 resections, palliative procedures, complete esophagogastrectomies and emergency surgeries.

Results:

A total of 284 patients were included; of the sample 65.4% were male,mean age of 64.5 years,75% were advanced cancers, 72.5% required a total gastrectomy, 30 lymph nodes harvest. Surgical morbidity and mortality were 17.2% and 1.7%. 5-year survival was 56.9%. The N+/T index could predict long-term survival in all de subgrups (p<0.0001), although had a reliable prediction in early GC (p=0.005), advanced GC (p<0.0001), signet ring cell GC (p<0.0001), proximal GC (p<0.0001) and distal GC (p<0.0001). The ROC curves N+/T index, LNR and T classification presented areas below the curve of 0.789, 0.786 and 0,790 respectively, without a significant statistical difference (p=0.96).

Conclusion:

The N+/T index is a reliable quotient in the prognostic evaluation of gastric adenocarcinoma patients who have been resected with curative intent.

Adjuvant Radiochemotherapy versus Chemotherapy Alone for Gastric Cancer: Implications for Target Definition

The INT0116 trial was a milestone study and laid the foundation for the adjuvant radiotherapy (RT) associated to concurrent chemotherapy (CT) for the treatment of gastric cancer (GC) after gastrectomy. However, it is still controversial whether adding RT to CT could further benefit D2-dissected GC patients. The ARTIST trial indicated that the addition of RT to CT did not have a positive impact on disease-free survival (DFS). Nevertheless, in a subgroup of 396 patients with positive pathological lymph nodes, combined treatment with RT was superior to CT alone. A similar randomized Chinese trial confirmed the superiority of adding RT to CT in terms of DFS for patients with D2 lymphadenectomy. However, several previous randomized studies provided inconsistent results with the benefits of combined treatment of RT and CT. The inconsistent results of several studies may be due to the differences between tumor epidemiology, treatment policies, and treatment outcomes. During the past decade, major progress in accurate target delineation utilizing RT technology has been observed. However, even though the use of adjuvant RT doubled after the INT-0116 trial results became public, the fraction of patients receiving adjuvant RT was still low according to the SEER database. The low rate of adjuvant RT can partially be explained by concern over toxicity while undergoing RT. Several studies have also defined the specific location of locoregional recurrence for postoperative RT in GC, but these studies are still limited. A number of retrospective studies demonstrated that the most prevalent nodal recurrence was outside the D2 dissection field. In order to overcome the restricted nature of a retrospective study and provide more individual radiation field determination, additional large-scale prospective multicenter studies are required to evaluate the optimal RT target.

Relationship between Clavien-Dindo classification and long-term survival outcomes after curative resection for gastric cancer: A propensity score-matched analysis

BACKGROUND

The impact of postoperative complications (POCs) on the long-term survival outcomes after curative resection for gastric cancer has seldom been reported. The purpose of this study was to evaluate the relationship between the severity of POCs and long-term survival outcomes after curative resection for gastric cancer.

METHODS

The study analyzed 3091 patients who underwent curative resection for gastric cancer in a single center between June 2009 and June 2015. Patients were divided into two groups based on the occurrence or absence of postoperative complications which were recorded using the Clavien-Dindo classification. Long-term survival outcomes were compared between groups after propensity score matching (PSM).

RESULTS

A total of 3091 patients were included in the entire cohort. After PSM, no significant difference in baseline data was observed between the complications (C) group (n = 375) and no complications (NC) group (n = 375). With a median follow-up of 51 months, POCs were associated with decreased 5-year overall survival (OS) (51.7% vs. 67.5%, P < 0.001), disease-free survival (DFS) (49.9% vs. 65.6%, P < 0.001), and disease-specific survival (DSS) (53.9% vs. 68.8%, P < 0.001). Increasing Clavien-Dindo grades from II to IV was significantly associated with a corresponding decrease in OS (60, 48.3, 34%, P = 0.010), DFS (58.3, 46.3, 32.1%, P < 0.001) and DSS (62.9, 50.3, 34%, P < 0.001). Multivariate analysis confirmed POCs was an independent prognostic factor for decreased OS, DFS, and DSS (all P < 0.05).

CONCLUSIONS

POCs had a negative impact on long-term survival outcomes after curative resection for gastric cancer. The negative effects were also increased with higher Clavien-Dindo grades.

Impact of lymph node ratio in selecting patients with resected gastric cancer for adjuvant therapy

BACKGROUND

The impact of adjuvant chemotherapy and chemo-radiation therapy in the treatment of resectable gastric cancer remains varied. We sought to define the clinical impact of lymph node ratio on the relative benefit of adjuvant chemotherapy or chemo-radiation therapy among patients having undergone curative-intent resection for gastric cancer.

METHODS

Using the multi-institutional US Gastric Cancer Collaborative database, 719 patients with gastric adenocarcinoma who underwent curative-intent resection between 2000 and 2013 were identified. Patients with metastasis or an R2 margin were excluded. The impact of lymph node ratio on overall survival among patients who received chemotherapy or chemo-radiation therapy was evaluated.

RESULTS

Median patient age was 65 years, and the majority of patients were male (56.2%). The majority of patients underwent either subtotal (40.6%) or total gastrectomy (41.0%), with the remainder undergoing distal gastrectomy or wedge resection (18.4%). On pathology, median tumor size was 4 cm; most patients had a T3 (33.0%) or T4 (27.9%) lesion with lymph node metastasis (59.7%). Margin status was R0 in 92.5% of patients. A total of 325 (45.2%) patients underwent resection alone, 253 (35.2%) patients received 5-FU or capecitabine-based chemo-radiation therapy, whereas the remaining 141 (19.6%) received chemotherapy. Median overall survival was 40.9 months, and 5-year overall survival was 40.3%. According to lymph node ratio categories, 5-year overall survival for patients with a lymph node ratio of 0, 0.01-0.10, >0.10-0.25, >0.25 were 54.1%, 53.1 %, 49.1 % and 19.8 %, respectively. Factors associated with worse overall survival included involvement of the gastroesophageal junction (hazard ratio 1.8), T-stage (3-4: hazard ratio 2.1), lymphovascular invasion (hazard ratio 1.4), and lymph node ratio (>0.25: hazard ratio 2.3; all P < .05). In contrast, receipt of adjuvant chemo-radiation therapy was associated with an improved overall survival in the multivariable model (versus resection alone: hazard ratio 0.40; versus chemotherapy: hazard ratio 0.45, both P < .001). The benefit of chemo-radiation therapy for resected gastric cancer was noted only among patients with lymph node ratio >0.25 (versus resection alone: hazard ratio R 0.34; versus chemotherapy: hazard ratio 0.45, both P < .001). In contrast, there was no noted overall survival benefit of chemotherapy or chemo-radiation therapy among patients with lymph node ratio ≤0.25 (all P > .05).

CONCLUSION

Adjuvant chemotherapy or chemo-radiation therapy was utilized in more than one-half of patients undergoing curative-intent resection for gastric cancer. Lymph node ratio may be a useful tool to select patients for adjuvant chemo-radiation therapy, because the benefit of chemo-radiation therapy was isolated to patients with greater degrees of lymphatic spread (ie, lymph node ratio >0.25).