Surgery for metastases for esophageal-gastric cancer in the real world: Data from the AGAMENON national registry

Radiomic-based models are able to predict the pathologic response to different neoadjuvant chemotherapy regimens in patients with gastric and gastroesophageal cancer: a cohort study

BACKGROUND

There is a clinical need to identify early predictors for response to neoadjuvant chemotherapy (NAC) in patients with gastric and gastroesophageal junction cancer (GC and GEJC). Radiomics involves extracting quantitative features from medical images. This study aimed to apply radiomics to build prediction models for the response to NAC.

METHODS

All consecutive patients with non-metastatic GC and GEJC undergoing NAC and surgical resection in an Italian high-volume referral center between 2005 and 2021 were considered eligible. In patients selected, the CT scans performed upon staging were reviewed to segment the tumor and extract radiomic features using MODDICOM. The primary endpoint was to develop and validate radiomic-based predictive models to identify major responders (MR: tumor regression grade TRG 1-2) and non-responders (NR: TRG 4-5) to NAC. Following an initial feature selection, radiomic and combined radiomic-clinicopathologic prediction models were built for the MR or NR status based on logistic regressions. Internal validation was performed for each model. Radiomic models (in the entire case series and according to NAC regimens) were evaluated using the receiver operating characteristic area under the curve (AUC), sensitivity, and negative predictive value (NPV).

RESULTS

The study included 77 patients undergoing NAC and subsequent tumor resection. The MR prediction model after all types of NAC (AUC of 0.876, CI 95% 0.786 - 0.966, sensitivity 83%, and NPV 96%) was based on a statistical feature. The models predicting NR among patients undergoing epirubicin with cisplatin and fluorouracil (ECF), epirubicin with oxaliplatin and capecitabin (EOX), or fluorouracil with oxaliplatin and docetaxel (FLOT) (AUC 0.760, CI 95% 0.639-0.882), oxaliplatin-based chemotherapy (AUC 0.810, CI 95% 0.692-0.928), and FLOT (AUC 0.907, CI 95% 0.818 - 0.995) were based on statistical, morphological and textural features.

CONCLUSIONS

The developed radiomic models resulted promising in predicting the response to different neoadjuvant chemotherapy strategies. Once further implemented on larger datasets, they could be valuable and cost-effective instruments to target multimodal treatment in patients with GC.

Salvage surgery for oesophageal cancer: The need for more intensive surveillance

BACKGROUND

There is currently no consensus on the role, method or frequency of surveillance following curative treatment of oesophageal cancer; re-investigation largely relying on symptom triggers which may delay detection of recurrence and impact survival. We hypothesised that intensive surveillance with endoscopy and imaging was more likely to detect recurrent or new cancer at a curable stage and this study examined the outcomes of this surveillance policy.

PATIENTS AND METHODS

A prospective database of curatively treated oesophageal carcinoma patients was interrogated for patients with new or recurrent disease detected on surveillance and amenable to salvage surgery. Surveillance was by clinic visits and endoscopy/biopsy 3-monthly to 3 years, 6-montjhly to 5 years and yearly thereafter while computerised tomography (CT) was performed 6-monthly for the first 3 years, annually to 5 years, and subsequently as indicated.

RESULTS

Of 205 patients treated with curative intent, 24 (11.7 %) underwent salvage surgery for 27 incidences of new or recurrent cancer. The median and 5-year survival was 51.8 months and 45.8 %, which was not inferior to the entire cohort of patients treated for cure, which was 30.2 months and 32.6 % respectively (p = 0.498).

CONCLUSIONS

Intensive surveillance identified almost 12 % of patients with recurrent or second primary cancer amenable to salvage surgery, with a non-inferior outcome to the remaining cohort. Further studies will refine surveillance intervals, techniques and follow-up duration for oesophageal cancer as for other GI malignancies.

Oligometastatic disease - a renaissance for surgery?

Half of the patients with esophageal cancer, cancer of the gastro-esophageal junction and gastric cancer present metastasis at the time of diagnosis. In addition, even patients originally thought to be free of metastasis will present metachronous metastasis in the course of the disease. These patients are considered incurable and current standard of care for metastatic esophageal, gastro-esophageal junction and gastric cancers is a systemic therapy without curative intention. However, patients presenting only a low metastatic load are now defined as oligometastatic disease and should benefit from an aggressive, multimodal therapy. We present here a review of recent publications investigating multimodal therapies for oligometastatic disease and showing that a systemic therapy combined with a resection of the primary tumor together with metastasis is associated with a better prognosis than a systemic therapy alone. We also give a precise focus on esophageal squamous cell carcinomas and adenocarcinomas of the gastro-esophageal junction and of the stomach. Interestingly, patients with oligometastatic cancer of the esophago-gastric junction can even be treated in curative intention with such a multimodal therapy as we present here in a short case report. In conclusion, new therapeutic strategies including multimodal approaches for oligometastatic disease have shown promising results in the last years and ongoing randomized prospective trials will provide us the evidence to include them in future European guidelines.

International consensus on the management of metastatic gastric cancer: step by step in the foggy landscape : Bertinoro Workshop, November 2022

BACKGROUND

Many gastric cancer patients in Western countries are diagnosed as metastatic with a median overall survival of less than twelve months using standard chemotherapy. Innovative treatments, like targeted therapy or immunotherapy, have recently proved to ameliorate prognosis, but a general agreement on managing oligometastatic disease has yet to be achieved. An international multi-disciplinary workshop was held in Bertinoro, Italy, in November 2022 to verify whether achieving a consensus on at least some topics was possible.

METHODS

A two-round Delphi process was carried out, where participants were asked to answer 32 multiple-choice questions about CT, laparoscopic staging and biomarkers, systemic treatment for different localization, role and indication of palliative care. Consensus was established with at least a 67% agreement.

RESULTS

The assembly agreed to define oligometastases as a "dynamic" disease which either regresses or remains stable in response to systemic treatment. In addition, the definition of oligometastases was restricted to the following sites: para-aortic nodal stations, liver, lung, and peritoneum, excluding bones. In detail, the following conditions should be considered as oligometastases: involvement of para-aortic stations, in particular 16a2 or 16b1; up to three technically resectable liver metastases; three unilateral or two bilateral lung metastases; peritoneal carcinomatosis with PCI ≤ 6. No consensus was achieved on how to classify positive cytology, which was considered as oligometastatic by 55% of participants only if converted to negative after chemotherapy.

CONCLUSION

As assessed at the time of diagnosis, surgical treatment of oligometastases should aim at R0 curativity on the entire disease volume, including both the primary tumor and its metastases. Conversion surgery was defined as surgery on the residual volume of disease, which was initially not resectable for technical and/or oncological reasons but nevertheless responded to first-line treatment.

Benefit of a multimodal approach combining chemotherapy and surgery in oligometastatic gastric cancer: experience from a tertiary referral center

Introduction

Gastric cancer (GC) is the fourth leading cause of cancer-related death worldwide with limited therapeutic options. The aim of this study was to analyze the value of adding surgery to the first-line treatment in patients with oligometastatic GC (OGC).

Methods

This retrospective study included patients with OGC who underwent induction chemotherapy followed by surgery of both primary tumor and synchronous metastasis between April 2012 and April 2022. Endpoints were overall survival (OS) and relapse-free survival (RFS) analyzed by the Kaplan-Meier method. Prognostic factors were assessed with the Cox model.

Results

Data from 39 patients were collected. All cases were referred to our multidisciplinary tumor board (MTB) to evaluate the feasibility of radical surgery. After a median follow-up of 33.6 months (mo.), median OS was 26.6 mo. (95% CI 23.8-29.4) and median RFS was 10.6 mo. (95% CI 6.3-14.8). Pathologic response according to the Mandard criteria (TRG 1-3, not reached versus 20.5 mo. for TRG 4-5; HR 0.23, p=0.019), PS ECOG ≤ 1 (26.7 mo. for PS ≤ 1 versus 11.2 mo. for PS >1; HR 0.3, p=0.022) and a low metastatic burden (26.7 mo. for single site versus 12.9 mo. for ≥2 sites; HR 0.34, p=0.039) were related to good prognosis. No major intraoperative complications nor surgery-related deaths occurred in our series.

Discussion

A sequential strategy of preoperative chemotherapy and radical surgical excision of both primary tumor and metastases was demonstrated to significantly improve OS and RFS. Multidisciplinary evaluation is mandatory to identify patients who could benefit from this strategy.

Successful R0 resection after chemotherapy, including nivolumab, for gastric cancer with liver metastases: three case reports

BACKGROUND

Advances in chemotherapy have increased clinical experience with conversion surgery for inoperable advanced gastric cancer. This report describes three patients with unresectable gastric cancer accompanied by multiple liver metastases. In all three patients, nivolumab resolved the liver metastases and subsequent conversion surgery achieved a pathological complete response.

CASE PRESENTATION

In Case 1, a 68-year-old man with clinical Stage IVB gastric cancer and multiple liver metastases initiated first-line therapy with SOX plus nivolumab. The patient completed 13 cycles; however, only nivolumab was continued for 3 cycles because of adverse events. Distal gastrectomy and partial hepatic resection were performed because of a significant reduction in the size of the liver metastases as observed on magnetic resonance imaging (MRI). In Case 2, a 72-year-old man with clinical Stage IVB gastric cancer and multiple liver metastases initiated first-line therapy with SOX. Because of the subsequent emergence of new liver metastases, the patient transitioned to ramucirumab plus paclitaxel as second-line therapy. Third-line therapy with nivolumab was initiated because of side effects. MRI revealed necrosis within the liver metastasis, and the patient underwent proximal gastrectomy and partial hepatectomy. In Case 3, a 51-year-old woman with clinical Stage IVB gastric cancer accompanied by multiple metastases of the liver and para-aortic lymph nodes began first-line therapy with SOX plus nivolumab. The patient completed 10 cycles; however, only nivolumab was continued for 5 cycles because of adverse events. Computed tomography showed a significant decrease in the size of the para-aortic lymph nodes, while MRI indicated the presence of a singular liver metastasis. Distal gastrectomy and partial hepatic resection were subsequently performed. In all three cases, MRI revealed the presence of liver metastases; however, pathological examination showed no viable tumor cells.

CONCLUSIONS

We herein present three cases in which chemotherapy, including nivolumab, elicited a response in patients with multiple unresectable liver metastases, ultimately culminating in R0 resection through conversion surgery. Although MRI showed liver metastases, pathological analysis revealed no cancer, underscoring the beneficial impact of chemotherapy.

Oncological outcomes of patients with oligometastatic oesophagogastric cancer

Oligometastatic oesophagogastric cancer was recently defined by consensus as the presence of no more than two metastases and an 18-week period of oncological stability during chemotherapy. The number of patients who fit this criterion and whether their oncological outcome differs from those with multi-metastatic disease is unknown. We analysed a database of 497 patients from 2017 to 2021 with metastatic oesophageal cancer. In total, 36 (7.2%) had oligometastatic disease and significantly improved median overall survival (mOS) versus multi-metastatic disease. In synchronous OMD, mOS was 26.8 months versus 7.3 months and in metachronous OMD, 38.6 months versus 6.1 months (both p < 0.0001). A subset of oligometastatic patients who underwent surgical management of their oligometastases after primary tumour resection demonstrated significantly increased mOS compared with systemic treatment alone (60 months versus 24.4 months; p < 0.038). Oligometastatic oesophagogastric cancer is associated with improved oncological outcome when compared to multi-metastatic disease. Further work is needed to identify patients who will benefit from aggressive treatment of metastatic oesophagogastric cancer.

Efficacy and safety of chemotherapy in young patients with advanced gastroesophageal adenocarcinoma: data from the Spanish AGAMENON-SEOM registry

BACKGROUND

Gastroesophageal adenocarcinoma in young adults (GCYA) counts for 10-15% of diagnoses. Previous studies have mainly focused on surgical outcomes in patients with resectable tumors; however, systemic therapy for advanced GCYA remains under-evaluated. This study aims to assess the efficacy-related outcomes and safety of first-line chemotherapy (CT) in younger versus older patients with advanced gastroesophageal adenocarcinoma.

METHODS

Patients with advanced gastroesophageal adenocarcinoma from the AGAMENON-SEOM registry treated with first-line polychemotherapy between January 2008 and October 2022 were included. We compared clinicopathological features, therapies received, efficacy-related outcomes, and toxicity between individuals aged < and ≥ 45 years.

RESULTS

Out of 3386 patients, 263 (7.8%) were < 45 years. Young patients exhibited a higher proportion of females affected, lower ECOG-PS ≥ 2, fewer comorbidities, and more aggressive disease-related features, such as higher proportion of diffuse subtype, signet-ring cells, plastic linitis, grade 3, peritoneal metastases and metastatic disease at diagnosis. They received more triple-agent combinations and underwent more surgeries in metastatic setting. No significant differences were observed between groups in overall response rate (53.1% vs. 52.3% in < and ≥ 45 years, respectively, p = 0.579), progression-free survival (6.1 vs. 6.83 months, p = 0.158) and overall survival (11.07 vs. 10.81 months, p = 0.82), even after adjusting for potential confounding factors. Grade 3-4 adverse events were comparable in both groups, although toxicity leading to treatment discontinuation was more frequent in older patients.

CONCLUSIONS

In the AGAMENON-SEOM registry, younger patients with GCYA exhibited more aggressive clinicopathological features, and despite receiving more aggressive treatments, similar efficacy outcomes and toxicity profiles were achieved compared to their older counterparts. In the AGAMENON-SEOM registry, GEAC in < 45 years showed more aggressive clinicopathological features and, although treated with more intense first-line CT regimens, similar efficacy outcomes and toxicity were achieved compared to older patients.

Surgical resection for liver recurrence after curative resection of pancreatic ductal adenocarcinoma

PURPOSE

This study aimed to evaluate the clinical significance of surgical resection for liver recurrence in patients with curatively resected pancreatic ductal adenocarcinoma.

METHODS

The medical records of patients with a liver recurrence after undergoing curative pancreatectomy for pancreatic ductal adenocarcinoma were retrospectively reviewed. Clinicopathological and prognostic factors were analyzed, as was the clinical impact of surgical resection for liver recurrence.

RESULTS

Overall, 502 patients underwent curative pancreatic ductal adenocarcinoma resection. Of the 311 patients with recurrence after curative pancreatectomy, 71 (23%) had an initial recurrence in the liver, with 35 having solitary recurrence (11%). Patients with solitary, two or three, or more than four recurrences had median overall survival times of 28.5, 18.0, and 12.2 months, respectively (p < 0.001). Surgical indications for liver recurrence in our institution included solitary tumor, good disease control under chemotherapy after recurrence for > 6 months, and sufficient remnant liver function. Ten patients who met our institutional policy inclusion criteria underwent liver resection. Among 35 patients with initially solitary liver recurrence, those who underwent liver resection outlived those who did not (57.6 months vs. 20.1 months, p < 0.001). In multivariate analysis of overall survival, solitary liver recurrence and liver resection were independent favorable prognostic factors in patients with initial liver recurrence.

CONCLUSION

In selected patients with solitary liver recurrence after curatively resected pancreatic ductal adenocarcinoma, liver resection may be a treatment option.

An International Multicenter Study Exploring Whether Surveillance After Esophageal Cancer Surgery Impacts Oncological and Quality of Life Outcomes (ENSURE)

OBJECTIVE

To determine the impact of surveillance on recurrence pattern, treatment, survival and health-related quality-of-life (HRQL) following curative-intent resection for esophageal cancer.

SUMMARY BACKGROUND DATA

Although therapies for recurrent esophageal cancer may impact survival and HRQL, surveillance protocols after primary curative treatment are varied and inconsistent, reflecting a lack of evidence.

METHODS

European iNvestigation of SUrveillance after Resection for Esophageal cancer was an international multicenter study of consecutive patients undergoing surgery for esophageal and esophagogastric junction cancers (2009-2015) across 20 centers (NCT03461341). Intensive surveillance (IS) was defined as annual computed tomography for 3 years postoperatively. The primary outcome measure was overall survival (OS), secondary outcomes included treatment, disease-specific survival, recurrence pattern, and HRQL. Multivariable linear, logistic, and Cox proportional hazards regression analyses were performed.

RESULTS

Four thousand six hundred eighty-two patients were studied (72.6% adenocarcinoma, 69.1% neoadjuvant therapy, 45.5% IS). At median followup 60 months, 47.5% developed recurrence, oligometastatic in 39%. IS was associated with reduced symptomatic recurrence (OR 0.17 [0.12-0.25]) and increased tumor-directed therapy (OR 2.09 [1.58-2.77]). After adjusting for confounders, no OS benefit was observed among all patients (HR 1.01 [0.89-1.13]), but OS was improved following IS for those who underwent surgery alone (HR 0.60 [0.47-0.78]) and those with lower pathological (y)pT stages (Tis-2, HR 0.72 [0.58-0.89]). IS was associated with greater anxiety ( P =0.016), but similar overall HRQL.

CONCLUSIONS

IS was associated with improved oncologic outcome in select cohorts, specifically patients with early-stage disease at presentation or favorable pathological stage post neoadjuvant therapy. This may inform guideline development, and enhance shared decision-making, at a time when therapeutic options for recurrence are expanding.

Stereotactic radiation therapy for oligometastatic esophagogastric adenocarcinoma: outcome and prognostic factors

OBJECTIVE

The aim of this study was to evaluate clinical results and prognostic factors in a cohort of patient with oligometastatic esophagogastric adenocarcinoma treated with stereotactic radiation therapy (SRT).

METHODS

This retrospective study included patients affected by 1-3 metastases treated with SRT from 2013 to 2021. Local control (LC), overall survival (OS), progression-free survival (PFS), time to polymetastatic dissemination (TTPD) and time to systemic therapy change/initiation (TTS) were evaluated.

RESULTS

Between 2013 and 2021, 55 patients were treated with SRT on 80 oligometastatic sites. Median follow-up was 20 months. Nine patients had local progression. 1 and 3 years LC was respectively 92 and 78%. 41 patients experienced further distant disease progression, median PFS was 9.6 months, 1 and 3 years PFS was respectively 40 and 15%. 34 patients died, median OS was 26.6 months, 1 and 3 years OS was respectively 78 and 40%. During follow-up, 24 patients changed or initiated a new systemic therapy; median TTS time was 9 months. 27 patients experienced poliprogression, 44% after 1 year and 52% after 3 years. Median TTPD was 8 months. The best local response (LR), tyming of metastases and PS were related with prolonged PFS on multivariate analysis. LR was correlated with OS at multivariate analysis.

CONCLUSION

SRT represents a valid treatment for oligometastatic esophagogastric adenocarcinoma. CR correlated with PFS and OS, while metachronous metastasis and a good PS correlated with a better PFS.

ADVANCES IN KNOWLEDGE

In selected gastroesopagheal oligometastatic patients, SRT can prolong OS Local response to SRT, metachronous timing of metastases and better PS improve PFS.Local response correlates with OS.

Evaluating the efficacy of post-operative chemotherapy after curative resection of stage IV gastric cancer with synchronous oligo metastasis: a multicenter retrospective study

BACKGROUND

Surgical resection of oligo-metastasis in gastric cancer (GC) is weakly recommended for patients without other incurable factors in the Japanese GC Treatment Guidelines. While post-operative chemotherapy is the standard treatment in patients with stage II or III GC, its efficacy for resected stage IV GC is unclear. This study aimed to evaluate the efficacy of post-operative chemotherapy after curative resection of GC with oligo-metastasis.

METHODS

We retrospectively reviewed the medical records of patients with GC who were diagnosed with synchronous oligo-metastasis at 20 institutions in Japan between 2007 and 2012. The selection criteria were: adenocarcinoma, stage IV with oligo-metastasis at liver or lymph node without other distant metastasis, curative resection including synchronous oligo-metastasis, and no prior treatment of GC before surgery.

RESULTS

A total of 110 patients were collected. Of the 94 eligible patients, 84 underwent gastrectomy with surgical resection of oligo-metastasis (39 [41%] liver metastasis and 55, [59%] distant lymph node metastasis), followed by post-operative chemotherapy with S-1 (S1: n = 55), S1 plus cisplatin (CS: n = 22), or Others (n = 7). Moreover, 10 patients did not receive post-operative chemotherapy (Non-Cx). The median overall survival (OS) was 35.2 and 11.1 months in the post-operative chemotherapy and Non-Cx groups (hazard ratio, 3.56; 95% confidence interval, 1.74-7.30; p < 0.001), respectively. In multivariable analysis, Non-Cx and age over 70 years were identified as poor prognostic factors for OS (p < 0.05).

CONCLUSIONS

Curative resection followed by post-operative chemotherapy in patients with GC with synchronous oligo-metastasis showed favorable survival.

Perspectives on the Management of Oligometastatic Disease in Esophago-Gastric Cancer

Gastric adenocarcinoma and esophageal cancer are the fifth and seventh most common cancer types worldwide. At the time of initial diagnosis, up to 50% of esophagogastric cancers present with distant metastatic lesions and are candidates for chemotherapy. Curative surgery in this stage is still an experimental approach. Only a small number of these metastatic patients show an oligometastatic disease with no uniform definition of what oligometastatic means in gastric cancer. Nevertheless, the question remains unanswered as to whether these patients are still candidates for curative concepts. Some studies have attempted to answer this question but have not been adequately designed to address the role of a curative-intended multimodal therapy in this setting. The current FLOT-5 is designed to potentially provide a definitive answer to the question of whether curatively intended surgery plays a role or is a disadvantage in this setting.

Does HER2 status influence in the benefit of ramucirumab and paclitaxel as second line treatment of advanced gastro-esophageal adenocarcinoma? Data from the AGAMENON-SEOM registry

PURPOSE

This study aimed to compare ramucirumab-paclitaxel versus chemotherapy in second-line (2L) advanced gastroesophageal cancer (aGEC) based on HER2 status and analyze prognostic factors.

METHODS

The study includes patients from the AGAMENON-SEOM registry with aGEC and known HER2 status who received 2L between 2016 and 2021. The Kaplan-Meier method was used to calculate progression-free survival (PFS) and overall survival (OS) and multivariable Cox regression analysis was done to adjust for confounding variables.

RESULTS

Of the 552 patients who met the selection criteria, 149 (26.9%) had HER2-positive aGEC, 89 were treated with chemotherapy, and 60 with ramucirumab-paclitaxel, and 403 had an HER2-negative aGEC, 259 were treated with chemotherapy, and 144 with ramucirumab-paclitaxel. In the whole sample, 2L PFS was 3.0 months (95% CI 2.8-3.2), 2L OS, 5.7 months (5.2-6.3), and ramucirumab-paclitaxel versus chemotherapy was associated with increased PFS (HR 0.64, 95% CI 0.53-0.78, p < 0.0001) and OS (HR 0.68, 0.55-0.83, p = 0.0002). Median PFS of ramucirumab- paclitaxel versus chemotherapy was 3.5 vs 2.8 months (HR 0.67, 0.54-0.83, p = 0.0004) in HER2-negative, and 4.7 vs 2.7 months (HR 0.57, 0.40-0.82, p = 0.0031) in HER2-positive aGEC, respectively. Median OS for ramucirumab-paclitaxel versus chemotherapy was 6.6 vs 5 months (HR 0.67, 0.53-0.85, p = 0.0007) in HER2-negative, and 7.4 vs 5.6 months (HR 0.70, 0.53-1.04, p = 0.083) in HER2-positive aGEC, respectively. ECOG-PS, tumor burden, Lauren subtype, and neutrophil-lymphocyte ratio were prognostic factors.

CONCLUSIONS

In patients with an aGEC from the AGAMENON-SEOM registry, 2L treatment with ramucirumab-paclitaxel was superior to chemotherapy in PFS, OS and response rate, independent of HER2 status.

Survival after Multimodal Treatment Including Surgery for Metastatic Esophageal Cancer: A Systematic Review

(1) Background: The management of metastatic esophageal cancer is more often limited to palliative chemotherapy. Limited data are available regarding the role of surgery that remains controversial. The aim of this systematic review is to assess the survival outcome of surgically treated metastatic esophageal cancer patients. (2) Methods: The present systematic review is designed using the PRISMA guidelines and has been registered with PROSPERO (CRD42019140306). Two reviewers independently searched and identified studies dealing with surgery for stage IV esophageal cancer in the Medline and Google Scholar databases between January 2008 and December 2019. (3) Results: Seven retrospective nonrandomized studies, totaling 1756 patients with stage IV esophageal cancer who underwent curative surgery, were included. Our analysis demonstrates a three-year overall survival rate of 23% (CI 95% 17–31) among patients undergoing surgery. Because only two comparative studies were identified, data compilation and relative risk evaluation through meta-analysis were not possible. (4) Conclusions: Multimodality treatment, including surgery in curative intent, seems associated with a significant chance of three-year overall survival. A prospective evaluation of this approach and validation of adequate selection criteria are needed.

SURGICAL TREATMENT IN CLINICAL STAGE IV GASTRIC CANCER: A COMPARISON OF DIFFERENT PROCEDURES AND SURVIVAL OUTCOMES

AIM

Even in clinical stage IV gastric cancer (GC), surgical procedures may be required to palliate symptoms or in an attempt to improve survival. However, the limited survival of these patients raises doubts about who really had benefits from it. This study aimed to analyze the surgical outcomes in stage IV GC treated with surgical procedures without curative intent.

METHODS

Retrospective analyses of patients with stage IV GC submitted to surgical procedures including tumor resection, bypass, jejunostomy, and diagnostic laparoscopy were performed. Patients with GC undergoing curative gastrectomy served as the comparison group.

RESULTS

Surgical procedures in clinical stage IV were performed in 363 patients. Compared to curative surgery (680 patients), stage IV patients had a higher rate of comorbidities and ASA III/IV classification. The surgical procedures that were performed included 107 (29.4%) bypass procedures (partitioning/gastrojejunal anastomosis), 85 (23.4%) jejunostomies, 76 (20.9%) resections, and 76 (20.9%) diagnostic laparoscopies. Regarding patients' characteristics, resected patients had more distant metastasis (p=0.011), bypass patients were associated with disease in more than one site (p<0.001), and laparoscopy patients had more peritoneal metastasis (p<0.001). According to the type of surgery, the median overall survival was as follows: resection (13.6 months), bypass (7.8 months), jejunostomy (2.7 months), and diagnostic (7.8 months, p<0.001). On multivariate analysis, low albumin levels, in case of more than one site of disease, jejunostomy, and laparoscopy, were associated with worse survival.

CONCLUSION

Stage IV resected cases have better survival, while patients submitted to jejunostomy and diagnostic laparoscopy had the worst results. The proper identification of patients who would benefit from surgical resection may improve survival and avoid futile procedures.

Sex and gender disparities in patients with advanced gastroesophageal adenocarcinoma: data from the AGAMENON-SEOM registry

Background

Recommendations for research articles include the use of the term sex when reporting biological factors and gender for identities or psychosocial or cultural factors. There is an increasing awareness of incorporating the effect of sex and gender on cancer outcomes. Thus, these types of analyses for advanced gastroesophageal adenocarcinoma are relevant.

Patients and methods

Patients with advanced gastroesophageal adenocarcinoma from the Spanish AGAMENON-SEOM registry treated with first-line combination chemotherapy were selected. Epidemiology, characteristics of the disease, treatment selection, and results were examined according to sex.

Results

This analysis included 3274 advanced gastroesophageal adenocarcinoma patients treated with combination chemotherapy between 2008 and 2021: 2313 (70.7%) men and 961 (29.3%) women. Tumors in females were more frequently HER2-negative (67.8% versus 60.8%; P < 0.0001), grade 3 (45.4% versus 36.8%; P < 0.001), diffuse (43.3% versus 26.5%; P < 0.0001), and signet ring cell histology (40.5 versus 23.9%; P < 0.0001). Peritoneal spread was more common in women (58.6% versus 38.9%; P < 0.0001), while liver burden was lower (58.9% versus 71.1%; P < 0.0001). There were no significant differences in treatment recommendation. Treatment doses, density, and duration were comparable between sexes. Women experienced more diarrhea (46% versus 37%; P < 0.0001), neutropenia (51% versus 43%; P < 0.0001), and anemia (62% versus 57%; P < 0.0001). After a median 59.6-month follow-up [95% confidence interval (CI) 54.5-70.8], there were no statistically significant differences between the sexes in progression-free survival [6.21 months (95% CI 5.8-6.5 months) versus 6.08 months (95% CI 5.8-6.3 months); log-rank test, χ² = 0.1, 1 df, P = 0.8] or in overall survival [10.6 months (95% CI 9.8-11.1 months) versus 10.9 months (95% CI 10.4-11.4 months); log-rank test: χ² = 0.6, 1 df, P = 0.5].

Conclusion

This sex analysis of patients with advanced gastroesophageal adenocarcinoma from the AGAMENON-SEOM registry receiving first-line polychemotherapy found no differences in survival. Although women had worse prognostic histopathology, metastatic disease pattern, and greater toxicity, treatment allocation and compliance were equivalent.

•

Sex and gender are determinants of health inequalities and may affect treatments, tolerability, and therapeutic outcomes.

•

According to sex, subtle biological and clinical differences exist in advanced gastroesophageal adenocarcinoma.

•

Women with advanced gastroesophageal adenocarcinoma experience greater toxicity with therapeutic results comparable with men.

•

Stratification and analysis by sex in studies of gastroesophageal adenocarcinoma should be considered.

Definition of oligometastatic esophagogastric cancer and impact of local oligometastasis-directed treatment: A systematic review and meta-analysis

BACKGROUND

Local treatment (metastasectomy or stereotactic radiotherapy) for oligometastatic disease (OMD) in patients with esophagogastric cancer may improve overall survival (OS). The primary aim was to identify definitions of esophagogastric OMD. A secondary aim was to perform a meta-analysis of OS after local treatment versus systemic therapy alone for OMD.

METHODS

Studies and study protocols reporting on definitions or OS after local treatment for esophagogastric OMD were included. The primary outcome was the maximum number of organs/lesions considered OMD and the maximum number of lesions per organ (i.e. 'organ-specific' OMD burden). Agreement was considered to be either absent/poor (< 50%), fair (50%-75%), or consensus (≥ 75%). The secondary outcome was the pooled adjusted hazard ratio (aHR) for OS after local treatment versus systemic therapy alone. The ROBINS tool was used for quality assessment.

RESULTS

A total of 97 studies, including 7 study protocols, and 2 prospective studies, were included. OMD was considered in 1 organ with ≤ 3 metastases (consensus). 'Organ-specific' OMD burden could involve bilobar ≤ 3 liver metastases, unilateral ≤ 2 lung metastases, 1 extra-regional lymph node station, ≤ 2 brain metastases, or bilateral adrenal gland metastases (consensus). Local treatment for OMD was associated with improved OS compared with systemic therapy alone based on 6 non-randomized studies (pooled aHR 0.47, 95% CI: 0.30-0.74) and for liver oligometastases based on 5 non-randomized studies (pooled aHR 0.39, 95% CI: 0.22-0.59). All studies scored serious risk of bias.

CONCLUSIONS

Current literature considers esophagogastric cancer spread limited to 1 organ with ≤ 3 metastases or 1 extra-regional lymph node station to be OMD. Local treatment for OMD appeared associated with improved OS compared with systemic therapy alone. Prospective randomized trials are warranted.

Multimodal treatment in oligometastatic gastric cancer

Gastric cancer is generally diagnosed at an advanced stage, especially in countries without screening programs. Previously, the metastatic stage was synonymous with palliative management, and surgical indications were only for symptomatic relief. However, this therapeutic option is associated with poor prognosis. A subgroup of patients with limited metastatic disease could benefit from intensive treatment. A combination of chemotherapy, immunotherapy, and targeted therapy could help either maintain a resectable state for oligometastatic disease or diminish the metastasis size to obtain a complete resection configuration. This latter strategy is known as conversion therapy and has growing evidence with favorable outcomes. Oncosurgical approach of metastatic disease could prolong survival in selected patients. The challenge for the surgeon and oncologist is to identify these specific patients to offer the best multimodal management. We review in this article the actual evidence for the treatment of oligometastatic gastric cancer with curative intent.

Identification of Thrombosis-Related Genes in Patients with Advanced Gastric Cancer: Data from AGAMENON-SEOM Registry

Advanced gastric cancer is one of the most thrombogenic neoplasms. However, genetic mechanisms underlying this complication remain obscure, and the molecular and histological heterogeneity of this neoplasm hinder the identification of thrombotic biomarkers. Therefore, our main objective was to identify genes related to thrombosis regardless of Lauren subtypes. Furthermore, in a secondary exploratory study, we seek to discover thrombosis-associated genes that were specific to each TCGA molecular subtype. We designed a nested case-control study using the cohort of the AGAMENON national advanced gastric cancer registry. Ninety-seven patients were selected—48 with and 49 without venous thromboembolism (using propensity score matching to adjust for confounding factors)—and a differential gene expression array stratified by Lauren histopathological subtypes was carried out in primary tumor samples. For the secondary objective, the aforementioned differential expression analysis was conducted for each TCGA group. Fifteen genes were determined to be associated with thrombosis with the same expression trend in both the intestinal and diffuse subtypes. In thrombotic subjects, CRELD1, KCNH8, CRYGN, MAGEB16, SAA1, ARL11, CCDC169, TRMT61A, RIPPLY3 and PLA2G6 were underexpressed (adjusted-p < 0.05), while PRKD3, MIR5683, SDCBP, EPS8 and CDC45 were overexpressed (adjusted-p < 0.05), and correlated, by logistic regression, with lower or higher thrombotic risk, respectively, in the overall cohort. In each TCGA molecular subtype, we identified a series of genes differentially expressed in thrombosis that appear to be subtype-specific. We have identified several genes associated with venous thromboembolism in advanced gastric cancer that are common to Lauren intestinal and diffuse subtypes. Should these genetic factors be validated in the future, they could be complemented with existing clinical models to bolster the ability to predict thrombotic risk in individuals with advanced gastric adenocarcinoma.

Resection of oesophageal and oesophagogastric junction cancer liver metastases - a summary of current evidence

Purpose

Metastatic oesophageal cancer is commonly considered as a palliative situation with a poor prognosis. However, there is increasing evidence that well-selected patients with a limited number of liver metastases (ECLM) may benefit from a multimodal approach including surgery.

Methods

A systematic review of the current literature for randomized trials, retrospective studies, and case series with patients undergoing hepatectomies for oesophageal and oesophagogastric junction cancer liver metastases was conducted up to the 31st of August 2021 using the MEDLINE (PubMed) and Cochrane Library databases.

Results

A total of 661 articles were identified. After removal of duplicates, 483 articles were screened, of which 11 met the inclusion criteria. The available literature suggests that ECLM resection in patients with liver oligometastatic disease may lead to improved survival and even long-term survival in some cases. The response to concomitant chemotherapy and liver resection seems to be of significance. Furthermore, a long disease-free interval in metachronous disease, low number of liver metastases, young age, and good overall performance status have been described as potential predictive markers of outcome for the resection of liver metastases.

Conclusion

Surgery may be offered to carefully selected patients to potentially improve survival rates compared to palliative treatment approaches. Studies with standardized patient selection criteria and treatment protocols are required to further define the role for surgery in ECLM. In this context, particular consideration should be given to neoadjuvant treatment concepts including immunotherapies in stage IVB oesophageal and oesophagogastric junction cancer.

Causal Considerations Can Inform the Interpretation of Surprising Associations in Medical Registries

An exploratory analysis of registry data from 2437 patients with advanced gastric cancer revealed a surprising association between astrological birth signs and overall survival (OS) with p = 0.01. After dichotomizing or changing the reference sign, p-values <0.05 were observed for several birth signs following adjustments for multiple comparisons. Bayesian models with moderately skeptical priors still pointed to these associations. A more plausible causal model, justified by contextual knowledge, revealed that these associations arose from the astrological sign association with seasonality. This case study illustrates how causal considerations can guide analyses through what would otherwise be a hopeless maze of statistical possibilities.

Prognosis of poorly cohesive gastric cancer after complete cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy (CYTO-CHIP study)

BACKGROUND

The incidence of gastric poorly cohesive carcinoma (PCC) is increasing. The prognosis for patients with peritoneal metastases remains poor and the role of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is controversial. The aim was to clarify the impact of gastric PCC with peritoneal metastases treated by CRS with or without HIPEC.

METHODS

All patients with peritoneal metastases from gastric cancer treated with CRS with or without HIPEC, in 19 French centres, between 1989 and 2014, were identified from institutional databases. Clinicopathological characteristics and outcomes were compared between PCC and non-PCC subtypes, and the possible benefit of HIPEC was assessed.

RESULTS

In total, 277 patients were included (188 PCC, 89 non-PCC). HIPEC was performed in 180 of 277 patients (65 per cent), including 124 of 188 with PCC (66 per cent). Median overall survival (OS) was 14.7 (95 per cent c.i. 12.7 to 17.3) months in the PCC group versus 21.2 (14.7 to 36.4) months in the non-PCC group (P < 0.001). In multivariable analyses, PCC (hazard ratio (HR) 1.51, 95 per cent c.i. 1.01 to 2.25; P = 0.044) was associated with poorer OS, as were pN3, Peritoneal Cancer Index (PCI), and resection with a completeness of cytoreduction score of 1, whereas HIPEC was associated with improved OS (HR 0.52; P < 0.001). The benefit of CRS-HIPEC over CRS alone was consistent, irrespective of histology, with a median OS of 16.7 versus 11.3 months (HR 0.60, 0.39 to 0.92; P = 0.018) in the PCC group, and 34.5 versus 14.3 months (HR 0.43, 0.25 to 0.75; P = 0.003) in the non-PCC group. Non-PCC and HIPEC were independently associated with improved recurrence-free survival and fewer peritoneal recurrences. In patients who underwent HIPEC, PCI values of below 7 and less than 13 were predictive of OS in PCC and non-PCC populations respectively.

CONCLUSION

In selected patients, CRS-HIPEC offers acceptable outcomes among those with gastric PCC and long survival for patients without PCC.

Surgery for metachronous oligometastatic esophageal cancer: Is there enough evidence?

Esophageal cancer is the sixth most common cause of cancer-related mortality worldwide. Despite advances in diagnostic modalities and treatment options, five-year survival rates are below 20%. Esophagectomy with extended lymph node dissection is the mainstay of treatment. More than 50% of patients experience recurrence within 1-3 years postoperatively. Recurrent disease may present locoregionally at the site of anastomosis or as recurrence through lymphatic spread in lymph node basins, as hematogenic metastasis, or as a combination of these. The standard treatment of recurrence is currently predicated on systemic chemotherapy and/or radiotherapy. Recent evidence suggests that surgical treatment of metachronous oligometastatic disease may be prognostically advantageous over medical management alone. Given the considerably low response rates to chemoradiotherapy, many institutions have adopted surgical treatment strategies for oligo-recurrent disease on a case-by-case basis. The aim of this article is to review the current evidence on the role of surgical treatment for metachronous oligometastases from esophageal cancer.

External validity of clinical trials with diverse trastuzumab-based chemotherapy regimens in advanced gastroesophageal adenocarcinoma: data from the AGAMENON-SEOM registry

BACKGROUND

Trastuzumab combined with cisplatin and fluoropyrimidines, either capecitabine or 5-fluorouracile (XP/FP), is the standard first-line treatment for advanced, HER2-positive, gastric cancer patients based on the ToGA trial. Despite the lack of phase III trials, many clinicians administer trastuzumab with alternative regimens. One meta-analysis suggests that substituting cisplatin for oxaliplatin might lead to greater efficacy and less toxicity.

METHODS

594 patients with HER2-positive gastroesophageal adenocarcinoma were recruited from the AGAMENON-SEOM registry. The objective was to evaluate the external validity of clinical trials with chemotherapy and trastuzumab.

RESULTS

The regimens used in at least 5% of the patients were XP (27%), oxaliplatin and capecitabine (CAPOX) (26%), oxaliplatin and 5-fluorouracil (FOLFOX) (14%), FP (14%), triplet with anthracycline/docetaxel (7%), and carboplatin-FU (5%). Median exposure to trastuzumab was longer with FOLFOX (11.4 months, 95% CI, 9.1-21.0) versus ToGA regimens (7.5, 6.4-8.5), p < 0.001. Patients with HER2-IHC 3+ cancers had higher response rates than those with IHC 2+/FISH+, odds-ratio 1.97 (95% CI, 1.25-3.09). The results achieved with CAPOX-trastuzumab were comparable to those attained with ToGA regimens. FOLFOX-trastuzumab was superior to ToGA schemes in terms of overall survival (OS), with a greater magnitude of effect in IHC 2+/FISH+ tumors (HR 0.47, 0.24-0.92) compared with IHC 3+ (HR 0.69, 0.49-0.96), and in diffuse (HR 0.37, 0.20-0.69) versus intestinal-type tumors (HR 0.76, 0.54-1.06).

CONCLUSION

We have updated the external validity of clinical trials with trastuzumab in first-line treatment of gastric cancer. Our data confirm the comparable outcomes of ToGA regimens and CAPOX-trastuzumab in clinical practice and point toward a possible benefit of FOLFOX-trastuzumab, contingent on the subtypes typically less sensitive to trastuzumab, to be confirmed in clinical trials.

Surgery for metachronous oligometastatic esophageal cancer: Is there enough evidence?

Esophageal cancer is the sixth most common cause of cancer-related mortality worldwide. Despite advances in diagnostic modalities and treatment options, five-year survival rates are below 20%. Esophagectomy with extended lymph node dissection is the mainstay of treatment. More than 50% of patients experience recurrence within 1-3 years postoperatively. Recurrent disease may present locoregionally at the site of anastomosis or as recurrence through lymphatic spread in lymph node basins, as hematogenic metastasis, or as a combination of these. The standard treatment of recurrence is currently predicated on systemic chemotherapy and/or radiotherapy. Recent evidence suggests that surgical treatment of metachronous oligometastatic disease may be prognostically advantageous over medical management alone. Given the considerably low response rates to chemoradiotherapy, many institutions have adopted surgical treatment strategies for oligo-recurrent disease on a case-by-case basis. The aim of this article is to review the current evidence on the role of surgical treatment for metachronous oligometastases from esophageal cancer.

External validity of docetaxel triplet trials in advanced gastric cancer: are there patients who still benefit?

BACKGROUND

The purpose of our study was to develop an online calculator to estimate the effect of docetaxel triplets (DPF) in first line of advanced gastric cancer (AGC), and to assess the external validity of docetaxel trials in individual patients.

METHODS

The study includes patients with HER2(-) AGC treated with platin and fluoropyrimidine (PF) or with DPF in first line. Treatment effect and interactions were assessed using Bayesian accelerated failure time models.

RESULT

The series comprises 1376 patients; 238 treated with DPF and 1138 with PF between 2008 and 2019. DPF was associated with increased progression-free survival (PFS) and overall survival (OS) with time ratio (TR) 1.27 (95% credible interval [CrI], 1.15-1.40), and TR 1.19 (95% CrI, 1.09-1.27), respectively. Serious adverse events were more common with DPF, particularly hematological effects (32% vs 22%). Younger participants received greater DPF dose density without achieving greater disease control, while severe toxicity was likewise higher. DPF yielded superior OS in Lauren intestinal (TR 1.27, 95% CrI, 1.08-1.11) vs diffuse subtype (TR 1.17, 95% CrI, 1.09-1.24) and the probability of increasing OS > 15% was 90% vs 67% in each subtype, respectively. The effect dwindles over time, which can be attributed to pathological changes and clinical practice changes.

CONCLUSION

Our study confirms the effect of DPF is highly dependent on several clinical-pathological variables, with discreet and gradually declining benefit over platinum doublets in later years, at the expense of increased toxicity. These results may help to underpin the idea that external validity of AGC trials should be revised regularly.

Perioperative FLOT chemotherapy plus surgery for oligometastatic esophagogastric adenocarcinoma: surgical outcome and overall survival

BACKGROUND

Guidelines do not recommend surgery for patients with oligometastatic disease from esophagogastric adenocarcinoma (EGAC), although some studies suggest a more favorable survival. We analyzed the outcome of oligometastatic EGAC receiving FLOT chemotherapy followed by surgery.

METHODS

The data of patients with either pre-therapeutic, post-neoadjuvant or intraoperative clinical diagnosis of oligometastatic EGAC were extracted from a prospective database of the 2009-2018 treatment period. 48 consecutive patients were identified with oligometastatic disease, who underwent perioperative chemotherapy plus surgery. We retrospectively analyzed surgical outcome and overall survival.

RESULTS

The overall 5-year survival was 18%. 12 patients (25%) with pre-therapeutic oligometastatic EGAC, who had no histologic vital tumor evidence of metastases after surgery had a survival rate of 48% compared to an 11% 5-year survival rate of 36 patients (75%), who had histologic vital tumor metastatic evidence after FLOT chemotherapy and surgical resection (p = 0.012). The survival rates after R0, R1 and R2 (non-resected metastases) resection were 21% (n = 33), 0% (n = 4) and 17% (n = 11), respectively (p = 0.273).

CONCLUSION

Oligometastatic EGAC is associated with poor overall survival even after complete resection of all tumor manifestations. The subgroup of patients with a complete histologic response of metastatic lesions to neoadjuvant FLOT shows 5-year survival rates similar to non-metastatic EGAC. Trial registration Not applicable.

Radiotherapy Combined with Chemotherapy for Regional Lymph Node Recurrence in Gastric Cancer

Purpose

Regional lymph node recurrence (RLNR) in gastric cancer is uncommon. We investigated the effects of radiotherapy combined with chemotherapy against limited RLNR and analyzed the regularity of regional lymph node recurrence and metastasis.

Patients and Methods

This retrospective study included 34 gastric cancer patients with limited RLNR after D2 lymphadenectomy between January 2012 and May 2018. All patients received systemic chemotherapy and local radiotherapy with median dose of 52.5 Gy (30–66 Gy in fractions of 1.8–3.0 Gy daily, five times weekly). All sites of recurrent and metastatic lymph nodes were collected and analyzed.

Results

The median follow-up was 19 months (range 7–60 months). After treatment, complete response and partial response were observed in 32.4% and 55.9% of patients, respectively. The median overall survival (OS) and progression-free survival (PFS) were 18 months and 13 months. On multivariate analysis, age (≤60 vs >60) was associated with a significantly better OS (p = 0.025) and radiation dose (<54 Gy vs ≥54 Gy) was considered as an independent prognostic factor for PFS (p = 0.000). During radiotherapy, three patients developed grade 3 gastrointestinal toxicity, and no deaths were related to the treatments. The most commonly metastatic lymph nodes were the No. 4, No. 3, No. 6, No. 5, No. 7, No. 9, and No. 8 nodes; the recurrent lymph nodes were mainly located in the No. 16b, No. 16a, No. 9, No. 14, No. 7, No. 13, and No. 8 nodes.

Conclusion

The selected gastric cancer patients with limited RLNR may benefit from radiotherapy combined with chemotherapy. High-dose radiotherapy (≥54 Gy) lead to better PFS and tend to extend OS. The major lymph node recurrence sites were in the gastric vascular region (especially No. 16a/b nodes).

Surgical management of oligometastatic disease in gastric cancer

A distinctive subset of metastatic gastric cancer (MGC) is oligometastatic disease (OMD), which is characterized by metastatic lesions limited in number and location. Although growing evidence mainly based on retrospective analysis or single center case series has shown favorable prognosis in the management of OMD in gastric cancer with aggressive local treatment, no existing guidelines explicitely address the definition of OMD and there are still controversial opinions on how to proceed in a new era with more effective systemic therapy selection. In this review, we present the current advances and evidence as well as controversial on the management of OMD in MGC, including the definition, diagnosis, local aggressive treatments especially surgery, prognostic factors, current ongoing randomized clinical studied as well as challenges facing the field.

Primary tumor resection of metastatic gastric cancer in a multimodal era: Two case reports

•

Metastatic gastric cancer has a poor prognosis.

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Multimodal era in gastric cancer has changed the outcomes of those patients.

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Good responders of metastatic gastric cancer should be discussed in multidisciplinary.

Introduction

Although no consensus has been reached on the role of surgical treatment for metastatic gastric cancer, some reports suggest promising results on patients with a small disease volume upon presentation. We present two cases of metastatic disease with a favorable outcome following surgical treatment.

Presentation of cases

The first case presented with an adenocarcinoma of the cardia, which was staged as oligometastatic due to a small liver nodule on segment III. Treatment consisted of neoadjuvant chemotherapy followed by laparoscopic esophagectomy and hepatectomy. The patient remains disease-free 62 months after surgery. Unlike the first case, the second case presented with a large number of liver nodules upon diagnosis, ruling out metastasectomy as a possible treatment. The tumor expressed HER2 receptors and responded favorably to chemotherapy plus trastuzumab for 34 months. At this point, disease progression was observed on the primary site, but the hepatic lesions remained stable. The patient underwent gastrectomy, resumed the chemotherapy regimen, and had a favorable outcome, with stability of the liver metastasis and no local recurrence following primary tumor resection.

Discussion

We illustrate through these two cases the effectiveness of a combined approach featuring perioperative chemotherapy and radical surgery for selected cases of oligometastatic gastric cancer, which we hope will spur further research on the topic.

Conclusion

Systemic treatment in metastatic gastric cancer may represent a novel treatment approach that allows surgical resection of the primary tumor in select cases.

Patients undergoing surgery for oligometastatic oesophageal cancer survive for more than 2 years: bootstrapping systematic review data

OBJECTIVES

Oesophageal cancer oligometastasis is a state of limited systemic disease characterized by ˂5 metastases. Without surgery average survival is 4–12 months. We sought to estimate patient prognosis following the surgical resection of oligometastatic disease from oesophageal cancer.

METHODS

Eligible studies were identified through systematic search of PubMed and the Cochrane Library (end-of-search date: 20 November 2019). We estimated cumulative 1-, 3- and 5-year, as well as overall survival using bootstrap methodology with 1 000 000 repetitions per outcome.

RESULTS

We investigated six studies involving 420 patients who underwent metastasectomy for oligometastasis from oesophageal cancer. Adenocarcinoma [77.3%; 95% confidence interval (CI) 62.8–87.3] was the most prevalent histological type followed by squamous cell carcinoma (22.7%; 95% CI 12.7–37.2). Metastatic lesions were typically synchronous (91.5%; 95% CI 87.5–94.1). Overall, 73.5% (95% CI 67.5–78.6) of the patients underwent resection of the primary and metastatic tumours synchronously. Neoadjuvant chemoradiotherapy was utilized in the majority of the patients (66.7%; 95% CI 49.5–80.3) followed by neoadjuvant chemotherapy (33.3%; 95% CI 19.6–50.5). The mean overall survival was 24.5 months (95% CI 14.4–34.6). One-year survival was 88.3% (95% CI 85.6–90.8). Three-year survival and 5-year survival were 36.3% (95% CI 15.3–7.3) and 23.8% (95% CI 12.0–35.7), respectively.

CONCLUSIONS

Patients undergoing surgical resection of oesophageal oligometastasis survive for more than 24 months. Therefore, loco-regional control of oligometastatic disease appears to improve survival by at least 100%.

Survival nomogram for patients with metastatic siewert type II adenocarcinoma of the esophagogastric junction: a population-based study

BACKGROUND

The aim of this study was to construct a nomogram to predict the survival of patients with metastatic Siewert Type II adenocarcinomas of the esophagogastric junction (AEG).

METHODS

Patients were identified using the Surveillance, Epidemiology, and End Results (SEER) database. Cox regression analysis was performed to assess the prognostic factors. A nomogram comprising independent prognostic factors was established and evaluated using C-indexes, calibration curves, and decision curve analyses.

RESULTS

In total 1616 eligible patients were enrolled. Race, age, bone metastasis, liver metastasis, lung metastasis, other metastasis sites, and distant lymph nodes metastasis were independent prognostic factors and were integrated to construct the nomogram. The nomogram had a C-index of 0.590 (95% CI: 0.569-0.611) in the training cohort and 0.569 (95% CI: 0.532-0.606) in the validation cohort. The calibration plots for the probabilities of 6-month and 1-year overall survival demonstrated there was an optimum between nomogram prediction and actual observation.

CONCLUSION

We developed and validated a nomogram to predict individual prognosis for patients with metastatic Siewert Type II AEG, and the risk stratification system based on the nomogram could effectively stratify the patients into two risk subgroups, which can help clinicians accurately predict mortality risk and recommend personalized treatment modalities.

Second-line treatment in advanced gastric cancer: Data from the Spanish AGAMENON registry

Background

Second-line treatments boost overall survival in advanced gastric cancer (AGC). However, there is a paucity of information as to patterns of use and the results achieved in actual clinical practice.

Materials and methods

The study population comprised patients with AGC in the AGAMENON registry who had received second-line. The objective was to describe the pattern of second-line therapies administered, progression-free survival following second-line (PFS-2), and post-progression survival since first-line (PPS).

Results

2311 cases with 2066 progression events since first-line (89.3%) were recorded; 245 (10.6%) patients died during first-line treatment and 1326/2066 (64.1%) received a second-line. Median PFS-2 and PPS were 3.1 (95% CI, 2.9–3.3) and 5.8 months (5.5–6.3), respectively. The most widely used strategies were monoCT (56.9%), polyCT (15.0%), ramucirumab+CT (12.6%), platinum-reintroduction (8.3%), trastuzumab+CT (6.1%), and ramucirumab (1.1%). PFS-2/PPS medians gradually increased in monoCT, 2.6/5.1 months; polyCT 3.4/6.3 months; ramucirumab+CT, 4.1/6.5 months; platinum-reintroduction, 4.2/6.7 months, and for the HER2+ subgroup in particular, trastuzumab+CT, 5.2/11.7 months. Correlation between PFS since first-line and OS was moderate in the series as a whole (Kendall’s τ = 0.613), lower in those subjects who received second-line (Kendall’s τ = 0.539), especially with ramucirumab+CT (Kendall’s τ = 0.413).

Conclusion

This analysis reveals the diversity in second-line treatment for AGC, highlighting the effectiveness of paclitaxel-ramucirumab and, for a selected subgroup of patients, platinum reintroduction; both strategies endorsed by recent clinical guidelines.

Sites of distant metastases and the cancer-specific survival of metastatic Siewert type II esophagogastric junction adenocarcinoma: a population-based study

BACKGROUND

The effect of distant metastasis on prognosis in patients with Siewert type II adenocarcinoma of the esophagogastric junction (AEG) remains elusive.

METHODS

Patients diagnosed as metastatic Siewert type II AEG were identified using the Surveillance, Epidemiology, and End Results (SEER) database. Kaplan-Meier survival analysis and a Cox proportional hazards analysis were performed to assess the effect of distant metastases sites.

RESULTS

We analyzed 1616 eligible patients. Liver was the most frequent metastatic site. For patients with isolated distant metastasis, the median survival time was 8, 7, 8, 10, and 11 months for patients with liver, bone, brain, lung, and distant lymph nodal metastasis, respectively (p = 0.011). The number of metastatic sites and the site of distant metastasis were independent prognostic factors for cancer-specific survival (CSS). In patients with isolated distant metastasis, using bone metastasis as reference, lung (p = 0.011) or distant lymph node metastasis (p = 0.030) was associated with better CSS, while patients with liver (p = 0.051) or brain (p = 0.488) metastasis had similar CSS compared to patients with bone metastasis.

CONCLUSION

CSS in metastatic Siewert type II AEG is dependent on the metastatic site and the number of metastatic sites.

Surgery to the primary tumor is associated with improved survival of patients with metastatic esophageal cancer: propensity score-matched analyses of a large retrospective cohort

The survival advantage of surgery to the primary tumor for patients with distant metastatic esophageal cancer has not been adequately evaluated. This study aims to investigate the role of surgery to the primary tumor in distant metastatic esophageal cancer and to evaluate possible different effects of surgery on survival of esophageal adenocarcinoma (EAC) and esophageal squamous cell carcinoma (ESCC). This study included a cohort of 4,367 metastatic esophageal cancer patients from the Surveillance, Epidemiology, and End Results (SEER) database, registered from January 2004 to December 2014. Kaplan-Meier and Cox proportional hazardous models were used to evaluate the overall survival (OS) and corresponding 95% confidence interval (CI). Propensity score matching (PSM) was used to adjust for potential baseline confounding. Both EAC (median OS for surgery group vs. no-surgery group-14.0 vs. 9.0 months, P < 0.001) and ESCC (median OS for surgery vs. no-surgery group-11.0 vs. 7.0 months, P = 0.002) experienced survival benefits from surgery. We found that surgery to the primary tumor, when combined with chemotherapy, was associated with improved survival for patients with M1b disease, both EAC and ESCC, with a greater benefit observed in younger patients, and those with EAC. While the present data indicate a potential survival benefit from surgery for some patients with metastatic esophageal cancer, it is possible that performance status and metastatic disease burden impacted patient selection, influencing these results. Further studies are needed to determine the role of surgery for patients with metastatic esophageal cancer.

Stage IV Gastric Cancer: The Surgical Perspective of the Italian Research Group on Gastric Cancer

Background/Aim: This work explored the prognostic role of curative versus non-curative surgery, the prognostic value of the various localizations of metastatic disease, and the possibility of identifying patients to be submitted to aggressive therapies. Patients and Methods: Retrospective chart review of stage IV patients operated on in our institutions. Results: Two hundred and eighty-two patients were considered; 73.4% had a single metastatic presentation. In 117 cases, a curative (R0) resection of primary and metastases was possible; 75 received a R1 resection and 90 a palliative R2 gastrectomy. Surgery was integrated with chemotherapy in multiple forms: conversion therapy, HIPEC, neo-adjuvant and adjuvant treatment. Median overall survival (OS) of the entire cohort was 10.9 months, with 14 months for the R0 subgroup. There was no correlation between metastasis site and survival. At multivariate analysis, several variables associated with the lymphatic sphere showed prognostic value, as well as tumor histology and the curativity of the surgical procedure, with a worse prognosis associated with a low number of resected nodes, D1 lymphectomy, pN3, non-intestinal histology, and R+ surgery. Considering the subgroup of R0 patients, the variables pT, pN and D displayed an independent prognostic role with a cumulative effect, showing that patients with no more than 1 risk factor can reach a median survival of 33 months. Conclusions: Our data show that the possibility of effective care also exists for Western patients with stage IV gastric cancer.

Management of Liver Oligometastatic Esophageal Cancer: Overview and Critical Analysis of the Different Loco-Regional Treatments

Esophageal cancer (EC) is an aggressive disease that is associated with a poor prognosis. Since metastastic EC is usually considered suitable only for palliative therapy with an estimated 5-year overall survival (OS) less than 5%, the optimal management of patients with liver oligometastatic EC (LOEC) is still undefined. The aim of this review is to provide an overview of the different treatment options for LOEC. A literature search was conducted using PubMed, Embase, and Cochrane to identify articles evaluating different treatment strategies for LOEC. Among 828 records that were identified, 20 articles met the inclusion criteria. These studies included patients who have undergone any type of surgical procedure and/or loco-regional therapy. Liver resection resulted in the best survival for patients with low tumor burden (3 lesions): 5-year OS 30–50% versus 8–12% after only chemotherapy (CHT). The 5-year OS of loco-regional therapies was 23% with a local recurrence risk ranging 0–8% for small lesions (2 to 3 cm). An aggressive multidisciplinary approach for LOEC patients may improve survival. Surgery seems to be the treatment of choice for resectable LOEC. If unfeasible, loco-regional therapies may be considered. In order to better select these patients and offer a chance of cure, prospective trials and a definition of treatment protocols are needed.

Surgery Strategies for Gastric Cancer With Liver Metastasis

Gastric cancer with liver metastasis is defined as advanced gastric cancer and remains one of the deadliest diseases with poor prognosis. Approximately 4–14% of patients with gastric cancers presented with liver metastases at the initial diagnosis. Owing to its incurability, first-line treatment for gastric cancer with liver metastases is systematic chemotherapy, whereas surgery is usually performed to alleviate severe gastrointestinal symptoms. However, continuously emerging retrospective studies confirmed the role of surgery in gastric cancer with liver metastases and showed significantly improved survival rate in patients assigned to a group of surgery with or without chemotherapy. Therefore, more and more convincing data that resulted from prospective randomized clinical trials is in need to clarify the surgery strategies in patients with gastric cancer with liver metastasis.

Cytoreductive Surgery With or Without Hyperthermic Intraperitoneal Chemotherapy for Gastric Cancer With Peritoneal Metastases (CYTO-CHIP study): A Propensity Score Analysis

PURPOSE

Gastric cancer (GC) with peritoneal metastases (PMs) is a poor prognostic evolution. Cytoreductive surgery (CRS) yields promising results, but the impact of hyperthermic intraperitoneal chemotherapy (HIPEC) remains controversial. Here we aimed to compare outcomes between CRS-HIPEC versus CRS alone (CRSa) among patients with PMs from GC.

PATIENTS AND METHODS

From prospective databases, we identified 277 patients with PMs from GC who were treated with complete CRS with curative intent (no residual nodules > 2.5 mm) at 19 French centers from 1989 to 2014. Of these patients, 180 underwent CRS-HIPEC and 97 CRSa. Tumor burden was assessed using the peritoneal cancer index. A Cox proportional hazards regression model with inverse probability of treatment weighting (IPTW) based on propensity score was used to assess the effect of HIPEC and account for confounding factors.

RESULTS

After IPTW adjustment, the groups were similar, except that median peritoneal cancer index remained higher in the CRS-HIPEC group (6 v 2; P = .003). CRS-HIPEC improved overall survival (OS) in both crude and IPTW models. Upon IPTW analysis, in CRS-HIPEC and CRSa groups, median OS was 18.8 versus 12.1 months, 3- and 5-year OS rates were 26.21% and 19.87% versus 10.82% and 6.43% (adjusted hazard ratio, 0.60; 95% CI, 0.42 to 0.86; P = .005), and 3- and 5-year recurrence-free survival rates were 20.40% and 17.05% versus 5.87% and 3.76% ( P = .001), respectively; the groups did not differ regarding 90-day mortality (7.4% v 10.1%, respectively; P = .820) or major complication rate (53.7% v 55.3%, respectively; P = .496).

CONCLUSION

Compared with CRSa, CRS-HIPEC improved OS and recurrence-free survival, without additional morbidity or mortality. When complete CRS is possible, CRS-HIPEC may be considered a valuable therapy for strictly selected patients with limited PMs from GC.

Optimal duration of first-line chemotherapy for advanced gastric cancer: data from the AGAMENON registry

BACKGROUND

The optimal duration of first-line chemotherapy for patients with advanced gastric cancer is unknown. Diverse clinical trials have proposed different strategies including limited treatment, maintenance of some drugs, or treatment until progression.

METHOD

The sample comprises patients from the AGAMENON multicenter registry without progression after second evaluation of response. The objective was to explore the optimal duration of first-line chemotherapy. A frailty multi-state model was conducted.

RESULTS

415 patients were divided into three strata: discontinuation of platinum and maintenance with fluoropyrimidine until progression (30%, n = 123), complete treatment withdrawal prior to progression (52%, n = 216), and full treatment until progression (18%, n = 76). The hazard of tumor progression decreased by 19% per month with the full treatment regimen. However, we found no evidence that fluoropyrimidine maintenance (hazard ratio [HR] 1.07, confidence interval [CI] 95%, 0.69-1.65) worsened progression-free survival (PFS) with respect to treatment until progression. Predictive factors for PFS were ECOG performance status, ≥ 3 metastatic sites, prior tumor response, and bone metastases. Toxicity grade 3/4 was more common in those who continued the full treatment until progression vs fluoropyrimidine maintenance (16% vs 6%).

CONCLUSION

The longer duration of the full initial regimen exerted a protective effect on the patients of this registry. Platinum discontinuation followed by fluoropyrimidine maintenance yields comparable efficacy to treatment up to PD, with a lower rate of serious adverse events.

Oligometastatic gastric cancer: An emerging clinical entity with distinct therapeutic implications

Gastric cancer (GC) remains responsible for a high burden worldwide being the third leading cause of cancer-related mortality. Most of patients present at an advanced stage at diagnosis and are thus candidates to standard chemotherapy resulting in median survival of less than 1 year. Oligometastatic gastric cancer is an increasingly recognized clinical entity characterized by limited metastatic spread that has been showing to benefit from aggressive multimodality strategies encompassing chemotherapy and surgery. The ongoing RENAISSANCE/AIO-FLOT5 (NCT02578368) phase III trial is aimed at evaluating if perioperative chemotherapy with FLOT in combination with surgical resection of the primary tumour and metastases could become the new standard of care for oligometastatic GC. In the meantime, in addition to currently available clinical parameters, the emerging predictive/prognostic role of biomarkers such mismatch repair deficiency/microsatellite instability high status needs to be specifically addressed also in this subgroup of GC to assist in patient selection.