Extended lymphadenectomy in elderly and/or highly co-morbid gastric cancer patients: A retrospective multicenter study

Disparities in overall survival of gastric cancer patients after radical gastrectomy: an age and rural-urban residence-based cohort study with propensity score matching analysis

This study estimated overall survival (OS) among gastric cancer patients stratified by age and rural-urban residence after radical gastrectomy. Patients (n = 286) undergoing curative gastrectomy were categorized into four groups based on age (older ≥ 60 years or younger < 60 years) and residence (rural or urban), including rural older (G1), urban older (G2), rural younger (G3) and urban younger (G4) groups. G1 presented with significantly more males, upper stomach cancers and total gastrectomies, while less patients receiving ≥ 4 cycles of adjuvant chemotherapy. The 5-year OS rates were 39.9% for G1, 61.1% for G2, 73.1% for G3, and 71.2% for G4, with a median OS of 47 months in G1 and not reached for other groups. OS was significantly worse in G1 than other groups (P < 0.05). Multivariate Cox regression identified age, type of gastrectomy, adjuvant chemotherapy, perineural invasion, pT category and pN category as independent prognostic factors. After propensity score matching, rural older patients continued to show significantly inferior OS compared to urban older (hazard ratio = 2.269 [1.274-4.042], P = 0.005) and rural younger (hazard ratio = 2.103 [1.116-3.961], P = 0.021) patients. Rural older patients suffered poorer OS after radical gastrectomy, highlighting the need for special attention and comprehensive treatment strategies.

Postoperative adjuvant chemotherapy in patients with gastric cancer based on the Nationwide Gastric Cancer Registry in Japan

The nationwide registry of the Japanese Gastric Cancer Association contains data related to the efficacy of adjuvant chemotherapy and prognostic factors across this patient population; elderly patients with advanced resectable gastric cancer are especially prevalent. Here, we analyzed data from 34,931 patients, who were treated between 2011 and 2013 at 421 hospitals in Japan. Although adjuvant chemotherapy was effective overall, 75 years or older elderly patients had a worse prognosis compared to younger patients. The most administered adjuvant chemotherapy was S-1 monotherapy. Adjuvant S-1 monotherapy was also effective for patients with pT1N2, pT1N3, and pT3N0 stage II tumors, as well as patients with other stage II and III malignancies. Independent prognostic factors for poor overall and relapse-free survival in patients at both stage II and stage III were age 75 or older, male, preoperative Eastern Cooperative Oncology Group performance status (ECOG-PS) 1 or more, preoperative renal dysfunction, undifferentiated adenocarcinoma, undergoing total gastrectomy, open laparotomy, no adjuvant chemotherapy, D1 lymphadenectomy, residual tumor R1 or R2, and Clavien-Dindo classification grade II or higher. Age 75 or older, renal dysfunction, ECOG-PS 1 and total gastrectomy were also significant risk factors for postoperative complications and lower compliance with adjuvant chemotherapy. Our analysis also revealed that adjuvant chemotherapy after resection of cancer of gastric remnant and postoperative chemotherapy against CY1 gastric cancer were also effective. We conclude that adjuvant chemotherapy is effective for all stage II and III patients including age 75 or older gastric cancer patients, in addition to distal gastrectomy, proximal gastrectomy, and pylorus-preserving surgery to avoid total gastrectomy may improve surgical outcomes and quality of life for elderly patients.

Lymph Node Dissection of Choice in Older Adult Patients with Gastric Cancer: A Systematic Review and Meta-Analysis

Background: Although the current literature has shown an increasing interest in surgical treatment of gastric cancer (GC) in older adults in recent years, there is still no consensus on proper management in this subgroup of patients. This study was designed with the objective of evaluating the current evidence that compares limited lymph node dissection with extended lymph node dissection in older adult patients (≥65 years) coursing with resectable GC. Methods: A systematic review of PubMed, Cochrane library, and ScienceDirect was performed according to PRISMA guidelines. All studies before 2018 were selected using a systematic review by Mogal et al. Studies were eligible for this meta-analysis if they were randomized controlled trials or non-randomized comparative studies comparing limited lymph node dissection versus extended lymph node dissection in patients with resectable GC taken to gastrectomy. Results: Seventeen studies and a total of 5056 patients were included. There were not any statistically significant differences in OS (HR = 1.04, CI95% = 0.72-1.51), RFS (HR = 0.92, CI95% = 0.62-1.38), or CSS (HR = 1.24, CI95% = 0.74-2.10) between older adult patients taken to limited and extended lymphadenectomy in addition to gastrectomy as the current surgical treatment for GC. Although a higher rate of major complications was observed in the extended lymphadenectomy group, this difference was not statistically significant in incidence between both groups of patients (OR = 1.92, CI95% = 0.75-4.91). Conclusions: Limited lymphadenectomy must be considered as the better recommendation for surgical treatment for GC in older adult patients, considering the oncological outcomes and lower rates of complications compared with more radical lymph node dissections.

Optimal extent of lymph node dissection for high-risk gastric cancer stratified by a national clinical database risk calculator

BACKGROUND

For patients with gastric cancer, a well-balanced treatment that considers both oncological aspects and surgical risk is demanded. This study aimed to explore the optimal extent of lymph node dissection (LND) for patients with gastric cancer according to surgical risk, stratified by the risk calculator system produced by the Japan National Clinical Database (NCD).

PATIENTS AND METHODS

We retrospectively evaluated 187 patients who underwent radical gastrectomy for gastric cancer. Using the median predicted anastomotic leak rate obtained by the NCD risk calculator as the cutoff value, we classified 97 and 90 patients as having high and low risks, respectively.

RESULTS

In low-risk patients, although limited LND reduced the postoperative intraabdominal infectious complications (IAIC), multivariate analysis revealed standard LND as an independent prognostic factor that improved Relapse-free survival (RFS). In high-risk patients, the rates of postoperative IAIC and RFS were similar between standard and limited LND. Pancreatic fistula was not observed in the limited dissection group.

CONCLUSION

Limited LND might be the optimal treatment strategy for patients with gastric cancer with high surgical risk.

Long-Term Impact of D2 Lymphadenectomy during Gastrectomy for Cancer: Individual Patient Data Meta-Analysis and Restricted Mean Survival Time Estimation

BACKGROUND

Debate exists concerning the impact of D2 vs. D1 lymphadenectomy on long-term oncological outcomes after gastrectomy for cancer.

METHODS

PubMed, MEDLINE, Scopus, and Web of Science were searched and randomized controlled trials (RCTs) analyzing the effect of D2 vs. D1 on survival were included. Overall survival (OS), cancer-specific survival (CSS), and disease-free survival (DFS) were assessed. Restricted mean survival time difference (RMSTD) and 95% confidence intervals (CI) were used as effect size measures.

RESULTS

Five RCTs (1653 patients) were included. Overall, 805 (48.7%) underwent D2 lymphadenectomy. The RMSTD OS analysis shows that at 60-month follow-up, D2 patients lived 1.8 months (95% CI -4.2, 0.7; p = 0.14) longer on average compared to D1 patients. Similarly, 60-month CSS (1.2 months, 95% CI -3.9, 5.7; p = 0.72) and DFS (0.8 months, 95% CI -1.7, 3.4; p = 0.53) tended to be improved for D2 vs. D1 lymphadenectomy.

CONCLUSIONS

Compared to D1, D2 lymphadenectomy is associated with a clinical trend toward improved OS, CSS, and DFS at 60-month follow-up.

Uncovering the Impact of Lymphadenectomy in Advanced Gastric Cancer: A Comprehensive Review

Gastric cancer is a significant health concern worldwide, and lymphadenectomy plays a crucial role in its treatment. However, there is ongoing debate regarding the optimal approach-D1 or D2 lymphadenectomy. This paper aims to synthesize the available evidence by conducting a comprehensive literature review and comparing the advantages and disadvantages of both techniques. The analysis includes studies, clinical trials, and systematic reviews that assess survival outcomes, morbidity, and quality of life. The selected studies revealed different outcomes associated with D1 and D2 lymphadenectomy, including lymph node harvest, disease control, recurrence rates, and overall survival. Postoperative complications also varied between the two techniques. These findings highlight the complex considerations involved in selecting the most suitable lymphadenectomy approach for individual patients. Therefore, the decision requires an individualized assessment that considers the potential benefits and risks of D1 and D2 techniques. A collaborative approach involving interdisciplinary teams is crucial for developing personalized treatment plans that optimize both oncological outcomes and postoperative quality of life.

The efficacy of adjuvant chemotherapy for older adults with stage II/III gastric cancer: a retrospective cohort study

BACKGROUND

Adjuvant chemotherapy is recommended as the standard treatment for patients with stage II/III resected gastric cancer. However, it is unclear whether older patients also benefit from an adjuvant chemotherapy strategy. This study aimed to investigate the clinical impact of adjuvant chemotherapy in older patients with stage II/III gastric cancer.

METHODS

This retrospective, real-world study analyzed 404 patients with stage II/III gastric cancer visited at our institute between January 2009 and December 2019. The clinical characteristics and outcomes of patients aged 70 years or older who received adjuvant chemotherapy were compared with those who did not receive this type of treatment. Propensity score analysis was performed to mitigate selection bias.

RESULTS

Of the 404 patients analyzed, 179 were aged 70 years or older. Fewer older patients received adjuvant chemotherapy than did younger patients (60.9% vs. 94.7%, respectively; P < 0.001). Among patients aged 70 years or older, those who received adjuvant chemotherapy had improved disease-free survival (DFS) (5-year DFS rate, 53.1% vs. 30.4%; P < 0.001) and overall survival (OS) (5-year OS rate, 68.7% vs. 52.1%; P = 0.002) compared to those who did not receive adjuvant chemotherapy. A similar survival benefit was observed in the propensity-matched cohort. Multivariate analysis showed that more advanced stage was associated with poorer OS. Receipt of adjuvant chemotherapy was independently associated with a decreased hazard of death (hazard ratio (HR), 0.37; 95% confidence intervals (CI), 0.20-0.68; P = 0.002).

CONCLUSIONS

Adjuvant chemotherapy may benefit older stage II/III gastric cancer patients aged ≥ 70 years. Further prospective studies are needed to confirm these findings.

Surgical and oncological outcomes of D1 versus D2 gastrectomy among elderly patients treated for gastric cancer

INTRODUCTION

Gastrectomy with D2 lymphadenectomy is considered standard treatment in gastric cancer (GC). Among Western patients, morbidity and mortality seem to increase in D2 relative to D1 lymphadenectomy. As elderly patients with co-morbidities are more prone to possible complications, it is unclear whether they benefit from D2 lymphadenectomy. This study aims to compare the short- and long-term results of D1 and D2 lymphadenectomy in elderly patients undergoing gastrectomy for GC.

METHODS

All elderly (⩾75 years) patients undergoing gastrectomy with curative intent for GC during 2000-2015 were included and grouped according to the level of lymph node dissection into the D1 or D2 group. Short-term surgical outcome included the Comprehensive Complication Index (CCI) and 30-day mortality. Long-term outcomes comprised overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS). Cox regression was used in multivariable analyses.

RESULTS

In total, 99 elderly patients were included in the study (51 in D1 group, 48 in D2 group). The median follow-up was 32.5 months. Patients in the D1 group were older and had a higher American Society of Anesthesiologist (ASA) score. Both groups had similar burden of postoperative complications (CCI 20.9 versus 22.6, p = 0.26, respectively) and 90-day mortality (2% for both groups). The OS, DSS, and DFS were similar between groups. Multivariable analysis adjusted for potential confounders detected no difference in the survival between the D1 and D2 groups.

CONCLUSIONS

Gastrectomy with D2 lymphadenectomy can be performed with low postoperative morbidity and mortality suggesting its use also in the elderly. Long-term outcomes seem similar but need further studies.

Is surgery the best treatment for elderly gastric cancer patients?

As the elderly population increases, the number of patients with gastric cancer has also been increasing. Elderly people have various preoperative problems such as malnutrition, high frequency of comorbidities, decreased performance status, and dementia. Furthermore, when surgery is performed, high postoperative complication rates and death from other diseases are also concerns. The goal of surgery in the elderly is that short-term outcomes are comparable to those in nonelderly, and long-term outcomes reach life expectancy. Perioperative problems in the elderly include: (1) Poor perioperative nutritional status; (2) Postoperative pneumonia; and (3) Psychological problems (dementia and postoperative delirium). Malnutrition in the elderly has been reported to be associated with increased postoperative complications and dementia, pointing out the importance of nutritional management. In addition, multidisciplinary team efforts, including perioperative respiratory rehabilitation, preoperative oral care, and early postoperative mobilization programs, are effective in preventing postoperative pneumonia. Furthermore, there are many reports on the usefulness of laparoscopic surgery for the elderly, and we considered that minimally invasive surgery would be the optimal treatment after assessing preoperative risk.

Laparoscopic distal gastrectomy in old-old patients: the first Western experience

BACKGROUND

This is the first Western study presenting short-term results on patients older than 80 years affected by gastric cancer and treated with laparoscopic distal gastrectomy.

METHODS

A multicentre prospective database on patients suffering from distal gastric cancer with age of ≥ 80 undergone to distal gastrectomy was analysed retrospectively. End points were length of hospital stay (LoS) after surgery, and times to stool passage and solid diet initiation, as well as postoperative complications. Univariate analysis of the differences between "laparoscopic" and "open" groups was performed with non-parametric tests.

RESULTS

Forty-six patients (median age: 83 years, median CCI: 5) undergone to distal gastrectomy were analysed. Seventeen out 46 patients (36.9%) underwent laparoscopic distal gastrectomy and extended lymphadenectomy was achieved in 25 cases (25/46, 54.3%). Median number of removed and examined nodes was higher in laparoscopic than in open group. Median LoS was significantly lower in the laparoscopic group (8 vs. 11 days). Complications occurred in 12 patients (26.1%): no significant differences between the two groups. There was a significant difference between the two surgical approaches in term of times for stool passage.

CONCLUSIONS

Laparoscopic approach seems to reduce the effect of the surgical trauma without compromising lymphadenectomy also in octogenarian patients with distal gastric cancer.

Is Sarcopenic Obesity an Indicator of Poor Prognosis in Gastric Cancer Surgery? A Cohort Study in a Western Population

BACKGROUND

The prognostic value of sarcopenic obesity in gastric cancer surgery remains debated. We aimed to evaluate the impact on outcomes of body composition and sarcopenic obesity after gastrectomy for gastric cancer.

METHODS

A retrospective review of prospectively maintained database of patients undergoing gastrectomy for gastric cancer from 2010 to 2017 was performed. Skeletal muscle mass and visceral adipose tissue were evaluated by preoperative computed tomography to define sarcopenia and obesity. Patients were classified in body composition groups according to the presence or absence of sarcopenia and obesity. Prognostic factors for survival were assessed by multivariate Cox analysis.

RESULTS

Of the 198 patients undergoing gastrectomy for gastric cancer, 90 (45.4%) patients were sarcopenic, 130 (67.7%) obese, and in the subclassification for body composition categories: 33 (17%) nonsarcopenic nonobesity, 75 (38%) non sarcopenic obesity, 35 (17%) sarcopenic nonobesity, and 55 (28%) sarcopenic obesity. No category of body composition was a predictor of postoperative complications and worse overall and disease-free survival outcomes. Multivariable analysis identified ASA III classification, preoperative weight loss > 10%, postoperative surgical re-intervention, and advanced tumor stage as independent prognostic factors for overall survival, and patients aged 75 years or older, preoperative weight loss > 10%, elevated netrophil-lymphocyte ratio, and advanced tumor stage as independent prognostic factors for disease-free survival.

CONCLUSIONS

Sarcopenia, obesity, and sarcopenic obesity were not associated with worse outcomes after gastric cancer surgery.

Laparoscopic gastrectomy for elderly gastric-cancer patients: comparisons with laparoscopic gastrectomy in non-elderly patients and open gastrectomy in the elderly

Background

The benefits of laparoscopic gastrectomy (LG) in elderly gastric-cancer patients still remain unclear. The purpose of this study was to evaluate the feasibility and safety of LG in elderly gastric-cancer patients.

Methods

We retrospectively evaluated patients who underwent LG or open gastrectomy (OG) between June 2009 and July 2015 in a single high-volume center. We compared surgical, short-term, and long-term survival outcomes among an elderly (≥70 years old) LG (ELG) group (n = 114), a non-elderly (<70 years old) LG (NLG) group (n = 740), and an elderly OG (EOG) group (n = 383).

Results

Except for extended time to first flatus, the surgical and short-term outcomes of the ELG group were similar to those of the NLG group. The ELG group revealed comparable disease-specific survival (DSS) rates to the NLG group (64.9% vs 66.2%, P = 0.476), although the overall survival (OS) rate was lower (57.0% vs 65.5%, P < 0.001) in the ELG group than in the NLG group. The ELG group showed longer operation time than the EOG group (236.4 ± 77.3 vs 179 ± 52.2 min, P < 0.001). The ELG group had less estimated blood loss (174.0 ± 88.4 vs 209.3 ± 133.8, P = 0.008) and shorter post-operative hospital stay (8.3 ± 2.5 vs 9.2 ± 4.5, P = 0.048) than the EOG group. The severity of complications was similar between the ELG and NLG groups. Multivariate analysis confirmed that LG was not a risk factor for post-operative complications.

Conclusions

LG is a feasible and safe procedure for elderly patients with acceptable short- and long-term survival outcomes.

Oncologic feasibility of D1+ gastrectomy for patients with cT1N1, cT2N0-1, or cT3N0 gastric cancer

INTRODUCTION

D2 gastrectomy has shown a survival benefit in patients with highly advanced gastric cancer; however, it remains unclear whether D2 gastrectomy is required for patients with early-stage advanced gastric cancer or early gastric cancer with limited lymph node metastasis. This analysis aimed to clarify the oncologic feasibility of D1+ gastrectomy in patients with cT1N1, cT2N0-1, or cT3N0 gastric cancer.

METHODS

This retrospective cohort analysis included 466 patients with cT1N1, cT2N0-1, or cT3N0 gastric cancer who received curative gastrectomy with either D2 or D1+ dissection. Surgical outcomes were compared between the D2 group (n = 406) and the D1+ group (n = 60).

RESULTS

The number of patients with higher age and higher comorbidity index was greater in the D1+ group than in the D2 group. Postoperative complications were significantly lower in the D1+ group than in the D2 group (10.0% vs. 26.8%, p = 0.004). No statistically significant difference in 5-year overall survival (p = 0.146) and disease-specific survival (p = 0.807) between the groups was noted. The incidence of local recurrences (p = 0.500) and that of lymph node recurrences (p = 1.000) were also similar between the groups. Multivariable analysis for overall survival identified age, clinical node-positive status, high Charlson score (≥3), advanced pathological stage (≥III), and postoperative complication (grade ≥ II) as independent prognostic factors. The propensity score-matched analysis showed very similar survival outcomes between the groups.

CONCLUSION

D1+ gastrectomy may be oncologically feasible for patients with cT1N1, cT2N0-1, or cT3N0 stage gastric cancer.

Challenges in the treatment of gastric cancer in the older patient

Gastric cancer is considered an age-related disease, with the majority of new cases in the UK diagnosed in individuals over the age of 75. At present most guidance related to the management of gastric cancer is based on trials undertaken in the fit, younger patient. Historically the elderly have been underrepresented in clinical trials, which frequently have a restricted inclusion to an upper age limit of 75. The European Society for Medical Oncology (ESMO) recommends use of a geriatric assessment to determine functional age when initiating treatment in elderly patients with gastric cancer, which has been shown to be a better predictor of treatment response than chronological age. The physiological changes that occur with age, including reduced organ function and pharmacokinetic and pharmacodynamic variability, together with impaired functional status, necessitate a more individualised approach to treatment decisions in the older patient to provide them with the same advantages from radical treatment and palliative chemotherapy as younger patients. This review summarises the current evidence extrapolated from trial data on how best to optimise treatment for elderly patients with gastric cancer.

The impact of race and socioeconomic status on the presentation, management and outcomes for gastric cancer patients: Analysis from a metropolitan area in the southeast United States

BACKGROUND

Socioeconomic disparities in gastric cancer have been associated with differences in care and inferior outcomes. We evaluated the presentation, treatment, and survival for patients with gastric cancer (GC) in a metropolitan setting with a large African American population.

METHODS

Retrospective cohort analysis of patients with GC (2003-2018) across a multi-hospital system was performed. Associations between socioeconomic and clinicopathologic data with the presentation, treatment, and survival were examined.

RESULTS

Of 359 patients, 255 (71%) were African American and 104 (29%) Caucasian. African Americans were more likely to present at a younger age (64.0 vs 72.5, P < .001), have state-sponsored or no insurance (19.7% vs 6.9%, P = .02), reside within the lowest 2 quintiles for median income (67.4% vs 32.7%, P < .001), and have higher rates of Helicobacter pylori (14.9% vs 4.8%, P = .02). Receipt of multi-modality therapy was not impacted by race or insurance status. On multivariable analysis, only AJCC T class (HR 1.68) and node positivity (HR 2.43) remained significant predictors of disease-specific survival.

CONCLUSION

Despite socioeconomic disparities, African Americans, and Caucasians with GC had similar treatment and outcomes. African Americans presented at a younger age with higher rates of H. pylori positivity, warranting further investigation into differences in risk factors and tumor biology.

Optimal treatment for elderly patients with resectable proximal gastric carcinoma: a real world study based on National Cancer Database

Background

High perioperative morbidity, mortality, and uncertain outcome of surgery in octogenarians with proximal gastric carcinoma (PGC) pose a dilemma for both patients and physicians. We aim to evaluate the risks and survival benefits of different strategies treated in this group.

Methods

Octogenarians (≥80 years) with resectable proximal gastric carcinoma who were recommended for surgery were identified from National Cancer Database during 2004–2013.

Results

Patients age ≥ 80 years with PGC were less likely to be recommended or eventually undergo surgery compared to younger patients. Patients with surgery had a significantly better survival than those without surgery (5-year OS: 26% vs. 7%, p < 0.001), especially in early stage patients. However, additional chemotherapy (HR: 0.94, 95% CI: 0.82–1.08, P = 0.36) or radiotherapy (HR: 0.97, 95% CI: 0.84–1.13, P = 0.72) had limited benefits. On multivariate analysis, surgery (HR: 0.66, 95% CI: 0.51–0.86, P = 0.002) was a significant independent prognostic factor, while extensive surgery had no survival benefit (Combined organ resection: HR: 1.88, 95% CI: 1.22–2.91, P = 0.004; number of lymph nodes examined: HR: 0.99, 95% CI: 0.97–1.00, P = 0.10). Surgery performed at academic and research (AR) medical center had the best survival outcome (5-year OS: 30% in AR vs. 18–27% in other programs, P < 0.001) and lowest risk (30-day mortality: 1.5% in AR vs. 3.6–6.6% in other programs, P < 0.001; 90-day mortality: 6.2% in AR vs. 13.6–16.4% in other programs, P < 0.001) compared to other facilities.

Conclusions

Less-invasive approach performed at academic and research medical center might be the optimal treatment for elderly patients aged ≥80 yrs. with early stage resectable PGC.

Surgical outcomes of gastrectomy with D1 lymph node dissection performed for patients with unfavorable clinical conditions

BACKGROUND

Gastric cancer (GC) patients with advanced age and/or multiple morbidities have limited expected survival and may not benefit from extended lymph node resection. The aim of this study was to evaluate the surgical outcomes of these GC patients who underwent gastrectomy with D1 dissection.

METHODS

We retrospectively reviewed all GC patients who underwent gastrectomy with curative intent from 2009 to 2017. The decision to perform D1 was based on preoperative multidisciplinary meeting, and/or intraoperative clinical judgment.

RESULTS

Among 460 enrolled patients, 73 (15.9%) underwent D1 lymphadenectomy and 387 (84.1%) D2 lymphadenectomy. Male gender, older age, American Society of Anesthesiologists score (ASA) III/IV, higher neutrophil-to-lymphocyte ratio (NLR) and higher Charlson Comorbidity Index (CCI) were more common in the D1 group. Postoperative major complications were significantly higher in D1 group (24.7% vs 12.4%, p < 0.001) and mostly related to clinical complications. Locoregional recurrence was higher in the D1 group (53.8% vs 39.5%, p = 0.330) however, without statistical significance. No difference was found in disease-free survival (DFS) between D1 and D2 patients with positive lymph nodes (p = 0.192), whereas overall survival was longer in the D2 group (p < 0.001). Multivariate analysis showed a statistically significant impact on survival of age ≥70 years, CCI ≥5, total gastrectomy, D1 lymphadenectomy and advanced stages (III/IV).

CONCLUSIONS

Frail patients had high surgical mortality even when submitted to D1 dissection. DFS was comparable to D2. Extent of lymphadenectomy in high-risk patients should take in account the expectation of a decrease in surgical risk with the possibility of impairment of long-term survival.

The safety and efficacy of gastrectomy for gastric cancer among octogenarians: a western population-based study

OBJECTIVE

The safety of minimally-invasive (MIG) and open gastrectomy (OG) in the older patients has been demonstrated in several international studies but has not been evaluated in the context of a large, Western population. The objective of this study was to evaluate the safety of gastrectomy by these two approaches among octogenarians in the United States.

MATERIALS AND METHODS

The National Cancer Database (2010-2014) was queried for patients with gastric adenocarcinoma who underwent MIG or OG. Disease and treatment characteristics and outcomes were compared across age groups (<65, 65-79, ≥80 years). Multivariable regression analysis was used to identify factors associated with 90-day mortality.

RESULTS

13,845 patients were identified who met study inclusion criteria, of which 2140 patients (16%) were aged ≥80 years. Among octogenarians, MIG was associated with slightly decreased length of stay (11.2 vs 12.7 days, p < .001) compared to OG, with no difference in the rate of margin-positive resections, adequate lymph node sampling, or readmission (p = .30-0.77). 90-day mortality for both OG (17%) and MIG (17.2%) was significantly higher among octogenarians compared to younger patients (p < .001). Treatment at an academic facility was an independent predictor of decreased 90-day mortality among octogenarians (OR 0.534, 95%CI 0.322-0.886, p = .015).

CONCLUSION

In this Western population, we report comparable oncologic and post-operative outcomes between MIG and OG. However, the overall post-operative mortality rate among octogenarians remains unacceptably high. Better patient selection criteria for surgery and efforts to refer these patients to higher volume, academic facilities should be considered to improve patient outcomes.

The 8th edition American Joint Committee on gastric cancer pathological staging classification performs well in a population with high proportion of locally advanced disease

BACKGROUND

The 8th edition of AJCC gastric cancer pathological staging system (AJCC8) derived from the IGCA database needs an external validated in cohorts with higher proportion of advanced disease.

PATIENTS AND METHODS

A total of 5386 gastric cancer patients treated at Chang Gung Memorial Hospital (CGMH) and Veteran General Hospital in Taipei (TVGH) were enrolled. Clinicopathological data of the IGCA series and the CGMH/TVGH cohort were compared. Cumulative survival curves of the CGMH/TVGH cohort as stratified by the AJCC7 and the AJCC8 were compared. Lymph node ratio (LNR) was analyzed in patients with N3b disease.

RESULTS

Patients in the CGMH/TVGH cohort were older and had more advanced tumor stage (stage III, 49% versus 26%, p < 0.001) than those in the IGCA cohort. The median survival of stages IIIA, IIIB, and IIIC as defined by the AJCC 8 were 49, 27 and 15 months, respectively, with narrower 95% confidence intervals, in comparison with 62, 30 and 18 months, respectively, as defined by the AJCC7. The AJCC8 exhibited better homogeneity within stages and discriminatory ability between stages, compared to the AJCC7. Six hundred and four patients with N3b disease were stratified by LNR into three subgroups, and their median survival were 31, 17, and 11 months, respectively (p < 0.001). LNR further appeared as a powerful outcome predictor of N3b disease (HR, 3.1).

CONCLUSION

The AJCC8 performs well in patients with high proportion of advanced gastric cancer. We recommend that LNR is a supplementary prognostic indicator for N3b disease.

Abdominal Drainage and Amylase Measurement for Detection of Leakage After Gastrectomy for Gastric Cancer

PURPOSE

To investigate the value of daily measurement of drain amylase for detecting leakage in gastric cancer surgery.

METHODS

This was a retrospective analysis including all patients who underwent a gastrectomy for gastric cancer. From January 2013 until December 2015, an intra-abdominal drain was routinely placed. Drain amylase was measured daily. Receiver operator characteristic curves were created to assess the ability of amylase to predict leakage. Sensitivity, specificity, and negative and positive predictive value of amylase in drain fluid were determined. Leakage of the gastrojejunostomy or esophagojejunostomy, enteroenterostomy, duodenal stump, or pancreas was diagnosed by CT scan, endoscopy, or during re-operation. From January 2016 until April 2017, no drain was inserted. Surgical outcome and postoperative complications were compared between both groups.

RESULTS

Median drain amylase concentrations were higher for each postoperative day in patients with leakage. The optimal cutoff value was 1000 IU/L (sensitivity 77.8%, specificity 98.2%, negative predictive value 96.6%). Sixty-seven consecutive procedures were performed with a drain and 40 procedures without. No differences in group characteristics were observed except for gender. Fourteen patients (13.1%) had a leakage. The incidence and severity of leakage were not different between the patients with and without a drain. There was no significant difference in time to diagnosis (1 vs. 0 days; p 0.34), mortality rate (7.5 vs. 2.5%; p 0.41), and median length of hospital stay (9 days in both groups; p 0.46).

CONCLUSION

Daily amylase measurement in drain fluid does not influence the early recognition and management of leakage in gastric cancer surgery.

Prognostic factors for short-term and long-term outcomes of gastric cancer surgery for elderly patients: 10 years of experience at a single tertiary care center

This retrospective study aimed to verify the short-term and long-term outcomes of elderly patients who underwent gastric resection for gastric cancer and to compare the results between younger and elderly patients. 222 Patients, who underwent gastrectomy between January 2005 and December 2014, were divided into 2 groups: ≤ 75 years old (group A) and > 75 years (group B). The groups were homogeneous except for more advanced pathological stage (p = 0.011) and higher number of comorbidities in group B (p < 0.001) and a higher rate of neoadjuvant or adjuvant complementary therapy in group A (p = 0.029 and p < 0.001). Perioperative morbidity rates were 38.7 and 65.5% (p = 0.001), and mortality rates were 2.5 and 7.9% (p = ns), respectively. The independent negative prognostic factors for morbidity were age older than 75 years [odds ratio (OR) 2.7], multiple organ resection (OR 2.4), and male gender (OR 1.8). The 36-month survival rates were 76.1% and 42.1% (p = 0.002) and disease-free survival rates were 85% and 76.3% (p = 0.017), respectively. Surgical indications should not be limited by age.

Characteristics of advanced gastric cancer with negative or only perigastric lymph node metastasis in elderly patients

OBJECTIVES

After gastrectomy with extended lymph node (LN) dissection, the damage of celiac plexus seems to cause of disorder of eating habits. To clarify the indication of gastrectomy with limited LN dissection for elderly patients, the pathological characteristics of advanced gastric cancer in elderly patients were examined in this study.

METHODS

Forty-seven patients aged ≥80 years with advanced gastric cancer (deeper than pT2) who underwent curative gastrectomy from 1998 to 2015 were enrolled. Patients were classified into two groups by extent of LN metastasis: Group A, with N0 or only perigastric LN metastasis (n = 33); Group B, LN metastasis beyond the perigastric area (n = 14). Pathological factors were then evaluated.

RESULTS

No significant differences were observed in age, sex, body mass index, American Society of Anesthesiologists physical status classification, serum level of carcinoembryonic antigen, surgical procedure, extent of LN dissection, and number of dissected LNs. Pathological findings showed no significant differences in tumor location, macroscopic type, histologic type, and lymphovascular invasion. However, significant differences were observed in tumor maximum diameter at the cut-off level of 40 mm (Group A: ≤40 mm, n = 10 and >40 mm, n = 23; Group B: ≤40 mm, n = 0 and >40 mm, n = 14; P = 0.02).

CONCLUSION

In the elderly patients, LN metastasis in advanced gastric cancer of ≤40 mm in diameter was limited to be within the perigastric area. Gastrectomy with only perigastric LN dissection may be adopted in these patients.

Necessity of D2 lymph node dissection in older patients ≥80years with gastric cancer

OBJECTIVES

This study analyzed the effect of D2 lymph node (LN) dissection on complications and survival in older patients with gastric cancer.

MATERIALS AND METHODS

A total of 103 octogenarian patients who underwent curative gastrectomy for gastric cancer were divided into two groups (D2 and D1) according to the extent of LN dissection and analyzed retrospectively for complications and survival.

RESULTS

No differences were observed in short-term postoperative outcomes, including complication rates, between the two groups. In a survival analysis, D2 LN dissection did not improve overall survival (OS) in any patient, including advanced cases. A Cox regression analysis revealed that the independent risk factors for OS were history of coronary artery disease (hazard ratio [HR], 11.095), postoperative short-term complications (HR, 9.939), and TNM stage (HR, 6.299). The extent of LN dissection was not an independent risk factor for OS, and D2 or more LN dissection (odds ratio, 10.89) increased the risk independently.

CONCLUSIONS

D2 or more LN dissection did not improve survival, but rather increased the risk of complications. Thus, LN dissection should be performed sparingly in octogenarian patients with gastric cancer.

Prognostic factors for gastrectomy in elderly patients with gastric cancer

Background

The aim of the present study was to investigate the age-specific prognostic factors in patients who underwent gastrectomy for gastric cancer.

Methods

The medical records of 366 patients with gastric cancer who underwent surgical resection at our hospital between January 2007 and December 2014 were retrospectively reviewed. Of the 366 patients, 117 were aged 75 years or older and 249 were aged 74 years or younger. All factors that were identified as significant using univariate analysis were included in the multivariate analysis.

Results

The median follow-up duration was 52.9 months (range, 1.0–117.5 months). We found that in patients aged 75 years or older, postoperative complications and the extent of cancer were independent prognostic factors of overall survival and disease-free survival. In contrast, in patients aged 74 years or younger, only the lymph node status and postoperative chemotherapy were independent prognostic factors for overall survival and disease-free survival, respectively.

Conclusions

Pathological outcomes and postoperative complications are important prognostic factors for survival in patients aged 75 years or older with gastric cancer, whereas pathological outcomes and postoperative chemotherapy are important prognostic factors for survival in patients aged 74 years or younger. Because the prevention of postoperative complications may contribute to improvements in the prognosis of elderly patients with gastric cancer, we suggest that it is necessary to consider limited surgery instead of radical surgery, depending on the patient’s general condition and co-morbidities.

Lymphadenectomy in elderly/high risk patients: should it be different?

The global aging of population will lead a greater number of elderly patients to undergo surgical procedure in a near future. Concerning gastric cancer, the impact of lymphadenectomy on survival has been demonstrated in RCTs, and extended lymphadenectomy is now considered as gold standard of treatment in non-early tumors. However, the role of age as a prognostic factor and the benefit of extended surgery in elderly/high-risk patients are not clearly defined yet. From our revision of literature, it seems that surgery for gastric cancer may have a further tailorization, considering not only the stage of disease, but also patients' age and comorbidities.

Lymphadenectomy: state of the art

The extent of lymphadenectomy in gastric cancer (GC) surgery has been for long time a matter of debate. Randomized trials performed in the West reported worse results of D2 dissection, in terms of postoperative complications and long-term survival benefit, than Eastern series and observational studies from specialized Western centers. However, long-term re-evaluation of such trials and in depth-analysis of other experiences demonstrated the potential benefit of D2 in reducing the probability of cancer-related death and the safety of this procedure when avoiding unnecessary spleno-pancreatectomy and in centers with ad adequate surgical volume. Nowadays, the D2 is considered the standard treatment in most guidelines all over the world. More limited procedures (D1, D1 plus) may be adequate in selected cases, and more extended dissections (D2 plus) could be indicated in advanced forms with high risk of metastases to distant nodes, but in specialized centers or in the setting of clinical studies. The integration with neoadjuvant therapies and multimodality approach could offer a chance of cure in groups of patients with poor results when approached with standard treatment.

Distant nodal metastasis: is it always an unresectable disease?

This article aims at analyzing the published literature concerning the treatment of patients with gastric cancer and distant nodal metastases, actually considered metastatic disease. A systematic search was undertaken using Medline, Embase, Cochrane and Web-of-Science libraries. No specific restriction on year of publication was used; preference was given to English papers. Both clinical series and literature reviews were selected. Only 11 papers address the issue of surgery for nodal basins outside the D2 dissection area. From these papers, in selected cases extended surgery may prove useful in prolonging survival, when a comprehensive therapeutic pathway including chemotherapy is scheduled. In conclusion, in presence of nodal metastases outside the loco-regional nodes, surgery may be considered for metastatic nodes in stations 13 and 16, in selected cases.