Preoperative and Postoperative Chemotherapy for Gastric Cancer

Comparison of proximal gastrectomy with tubular esophagogastric anastomosis and total gastrectomy with Roux-en-Y reconstruction in the treatment of adenocarcinoma of the esophagogastric junction of Siewert type II/III at stage II

BACKGROUND

Tubular anastomosis is commonly used in proximal gastrectomy; however, its use in stage II esophagogastric conjugate cancer is currently unclear. In this study, we investigated the short- and long-term clinical outcomes of Siewert II/III adenocarcinoma of the esophagogastric junction after modified proximal gastrectomy with tubular esophagogastric anastomosis compared with total gastrectomy with Roux-en-Y reconstruction.

METHODS

We collected the clinical data of patients who underwent proximal gastrectomy tubular esophagogastric anastomosis (PG-TEA) and total gastrectomy Roux-en-Y reconstruction (TG-RY) from October 2015 to October 2018. The clinical characteristics, postoperative quality of life, nutritional status, and long-term survival outcomes of the two groups were compared.

RESULTS

There were 43 patients in the PG-TEA group and 80 patients in the TG-RY group, and there was no significant difference between the baseline data of the groups. The operation time of the PG-TEA group was shorter, there was less intraoperative bleeding, and the feeding time was earlier, which was conducive to postoperative recovery. Reflux esophagitis was more evident in the PG-TEA group than in the TG-RY group, and there was no significant difference in the incidence of anastomotic ulcers or other complications. Three months after surgery, the nutritional status of the PG-TEA group was better than the TG-RY group. By the 6th postoperative month, there was no significant difference between the two groups. Regarding quality of life, the PG-TEA group was superior to the TG-RY group in terms of diarrhea and dumping syndrome. In addition, the PG-TEA group had higher satisfaction with daily life and higher-quality meals. There was no significant difference in overall survival between the two groups.

CONCLUSIONS

Proximal gastrectomy tubular gastroesophageal anastomosis is a surgical procedure for stage II Siewert type II and III AEG. It achieves similar clinical outcomes to those after total gastrectomy and can be further applied in the clinic.

"Four-Step Procedure" of laparoscopic exploration for gastric cancer in West China Hospital: a retrospective observational analysis from a high-volume institution in China

BACKGROUND

The preoperative work-up has limitations on finding peritoneal dissemination (PD) in gastric cancer patients. Laparoscopic exploration (LE) can discover radiographically occult PD, obtain accurate stage and avert futile laparotomy. The aim of our study was to introduce "Four-Step Procedure" LE in West China Hospital and further evaluate its safety and feasibility.

METHODS

We conducted a retrospective analysis on 165 patients from July 2016 to December 2017 who underwent "Four-Step Procedure" LE in gastrointestinal surgery department of West China Hospital. All the patients were diagnosed with gastric adenocarcinoma without explicit distant metastasis through Computed Tomography and/or Gastrointestinal Ultrasonography. Peritoneal lavage cytological examination (CY) was routinely performed during LE in our research. The "Four-Step" technical process of LE was introduced comprehensively. The clinicopathologic features and the presence of PD or CY at LE were analyzed, and the stratified analysis by cT and cN stages on the proportion of P1 and/or CY1 was also reported in this study.

RESULTS

Total of 165 patients accepted LE in our study, among these patients: 27 (16.4%) patients with P1 and/or CY1: 19 (11.5%) patients were found PD (P1), 17 (10.3%) patients with positive cytological examination (CY1) and 9 (3.6%) patients with P1Cy1. The stratified analysis by cT stage indicated that there was no P1 and/or Cy1 in cT1-cT2 stages, 1 (2.7%) patient with P1 and 1 (2.7%) with Cy1 in cT3 stage, 18 (20.0%) patients with P1 and 16 (17.8%) with Cy1 in cT4 stage. After LE, there were 74 (44.8%) patients underwent laparoscopic assistant gastrectomy, 25 (15.2%) patients with open gastrectomy, 50 (30.3%) patients with neoadjuvant chemotherapy and 16 (9.7%) patients with palliative chemotherapy and/or conversion therapy.

CONCLUSION

"Four-Step Procedure" LE is reliable and feasible for gastric cancer. From our study, LE has unique superiority on ascertaining PD and cytological examination and LE should be recommended in cT4 stage gastric cancer before resection.

NIR triggered liposome gold nanoparticles entrapping curcumin as in situ adjuvant for photothermal treatment of skin cancer

We report the synthesis of a biodegradable liposome gold nanoparticles for curcumin (Au-Lipos Cur NPs) delivery. This entrapped curcumin served as an in situ adjuvant for photothermal therapy. Curcumin was loaded in Au-Lipos NPs with an encapsulation efficiency of ∼70%. The gold coating enabled the NPs to specifically absorb NIR light (780nm) by virtue of Surface Plasmon Resonance (SPR) and this light energy was converted to heat. The generated heat destabilized the liposomal core enhancing the release of encapsulated curcumin. Photothermal transduction efficacy of Au-Lipos NPs (loaded with curcumin) showed a significant temperature rise upon laser irradiation causing irreversible cellular damage. In vitro photothermal effect and intracellular uptake was evaluated in B16 F10 (melanoma) cell line. Au-Lipos Cur NPs showed significantly enhanced uptake when compared with free curcumin. Enhancement in cancer cell cytotoxicity was observed in Au-Lipos Cur NPs treated group upon laser irradiation owing to curcumin. Our findings indicate that curcumin could serve as a potential in situ adjuvant for photothermal therapy of melanoma.

Present and future roles of FDG-PET/CT imaging in the management of gastrointestinal cancer: an update

Positron emission tomography/computed tomography (PET/CT) integrated with 2-[18F]fluoro-2-deoxy-D-glucose (FDG) is a useful tool for acquisition of both glucose metabolism and anatomic imaging data, as only a single device and one diagnostic session is required, thus opening a new field in clinical oncologic imaging. FDG-PET/CT has been successfully used for initial staging, restaging, assessment of early treatment response, evaluation of metastatic disease response, and prognostication of intestinal cancer as well as various malignant tumors. We reviewed the current status and role of FDG-PET/CT for management of patients with esophageal cancer, gastric cancer, and colorectal cancer, with focus on both its usefulness and limitations.

Regenerating Family Member 4 (Reg4) Enhances 5-Fluorouracil Resistance of Gastric Cancer Through Activating MAPK/Erk/Bim Signaling Pathway

BACKGROUND Reg4, a member of the Reg multigene family, is highly upregulated in many gastrointestinal cancers including gastric cancer (GC). The enhanced expression of Reg4 is associated with the resistance of GC to 5-fluorouracil (5-FU), while the underlying mechanism is not clear. The aim of the present study was to explore the resistant mechanism underlying 5-FU resistance. MATERIAL AND METHODS Reg4 expression was assessed by Western blot analysis for SGC-7901, BGC-823, AGS, MKN28, and MKN45. Synthetic short single strand RNA oligonucleotides and Flag-Reg4 plasmid were used to investigate the biological function of Reg4 in vitro. The cell viability assay was performed by MTT. Flow cytometry was carried out to measure the apoptosis caused by 5-FU. Reverse-transcriptase quantitative polymerase chain reaction (RT-qPCR) was used to examine the expression of 5-FU metabolism related enzymes. The effect of Reg4 on intracellular signaling was evaluated by Western blot. RESULTS Western blot analysis of 5 GC cells showed that Reg4 was low or null in SGC-7901 and BGC-823, while high in AGS, MKN28, and MKN45. Over-expression of flag-Reg4 in SGC-7901 led to an increase in cell viability and lower apoptosis with 5-FU treatment. In contrast, siRNA knockdown of Reg4 enhanced 5-FU induced apoptosis. However, over-expression or knockdown of Reg4 had no significant influence on the expression of 5-FU metabolic enzymes. Further investigation revealed that Reg4 could activate Erk1/2-Bim-caspase3 cascade. CONCLUSIONS Reg4 inhibited apoptosis through regulating MAPK/Erk/Bim signaling pathway and thereby enhanced the resistance of GC to 5-FU.

Preoperative Helicobacter pylori Infection is Associated with Increased Survival After Resection of Gastric Adenocarcinoma

BACKGROUND

Limited data exist on the prognosis of preoperative Helicobacter pylori (H. pylori) infection in gastric adenocarcinoma (GAC).

METHODS

Patients who underwent curative-intent resection for GAC from 2000 to 2012 at seven academic institutions comprising the United States Gastric Cancer Collaborative were included in the study. The primary end points of the study were overall survival (OS), recurrence-free survival (RFS), and disease-specific survival (DSS).

RESULTS

Of 559 patients, 104 (18.6 %) who tested positive for H. pylori were younger (62.1 vs 65.1 years; p = 0.041), had a higher frequency of distal tumors (82.7 vs 71.9 %; p = 0.033), and had higher rates of adjuvant radiation therapy (47.0 vs 34.9 %; p = 0.032). There were no differences in American Society of Anesthesiology (ASA) class, margin status, grade, perineural invasion, lymphovascular invasion, nodal metastases, or tumor-node-metastasis (TNM) stage. H. pylori positivity was associated with longer OS (84.3 vs 44.2 months; p = 0.008) for all patients. This relationship with OS persisted in the multivariable analysis (HR 0.54; 95 % CI 0.30-0.99; p = 0.046). H. pylori was not associated with RFS or DSS in all patients. In the stage 3 patients, H. pylori was associated with longer OS (44.5 vs 24.7 months; p = 0.018), a trend of longer RFS (31.4 vs 21.6 months; p = 0.232), and longer DSS (44.8 vs 27.2 months; p = 0.034).

CONCLUSIONS

Patients with and without preoperative H. pylori infection had few differences in adverse pathologic features at the time of gastric adenocarcinoma resection. Despite similar disease presentations, preoperative H. pylori infection was independently associated with improved OS. Further studies examining the interaction between H. pylori and tumor immunology and genetics are merited.

An enzymatically fortified ginseng extract inhibits proliferation and induces apoptosis of KATO3 human gastric cancer cells via modulation of Bax, mTOR, PKB and IκBα

Accumulative evidence suggests ginseng extract and/or its major components, ginsenosides and compound K, a metabolized ginseng saponin, have anti-cancer effects. In the present study, the effects of a ginseng butanolic extract (GBX) and an enzymatically fortified ginseng extract (FGX), with enriched ginsenosides and compound K, on the growth of KATO3 human gastric cancer cells were investigated using a cell viability assay. While treatment with GBX at 31.25-125 mg/ml for 24 h did not affect the proliferation of KATO3 cells, FGX under the same conditions inhibited cell proliferation in a concentration-dependent manner. Furthermore, Annexin V/PI-staining and flow cytometric analysis demonstrated that the population of apoptotic KATO3 cells was increased following treatment with FGX, which was greater than in the GBX-treated cells, suggesting that FGX had a stronger apoptotic effect than GBX. To investigate the underlying mechanism of the cytostatic and cytotoxic effects of the ginseng extracts, apoptosis-associated proteins were assessed using western blot analysis. The data revealed higher expression levels of B-cell lymphoma 2-associated X protein (Bax), lower expression of nuclear factor of kappa light polypeptide gene enhancer in B-cells inhibitor α (IκBα) and reduced phosphorylation of mammalian target of rapamycin (mTOR) and protein kinase B (PKB) in the FGX-treated KATO3 cells than in the GBX-treated cells. Collectively, these results demonstrated for the first time, to the best of our knowledge, that FGX had stronger anti-proliferative and pro-apoptotic effects on KATO3 cells than GBX. The anti-proliferative and/or pro-apoptotic effects of FGX appeared to be mediated via the upregulation of Bax, IκBα proteolysis (activation of nuclear factor-κB) and the blocking of mTOR and PKB signals.

Synergistic antitumor effects of combined deguelin and cisplatin treatment in gastric cancer cells

Deguelin is a naturally occurring rotenoid with marked chemopreventive and antitumor activity. Cisplatin, characterized by damaging DNA, is widely used in the chemotherapy of malignancies, including gastric cancer. The present study investigated whether synergistic effects exist between the combination of deguelin and cisplatin, and the possible mechanism in vitro. The interactive effects of deguelin in combination with various concentrations of cisplatin were evaluated in the human gastric cancer MGC-803 cell line. The inhibition of cell proliferation was determined by 3-(4,5)-dimethylthiazol(-2-yl)-2,5-diphenyltetrazolium bromide assay and the mechanisms underlying the effects were further evaluated by western blot analysis. The results revealed that the combined treatment of deguelin and cisplatin exhibited a marked inhibition of MGC-803 cell proliferation when compared with that of the single therapies in vitro. In addition, isobologram analysis revealed that this combined treatment showed a synergistic effect. These observations may have promising therapeutic value for gastric cancer and thus warrant further investigation.

HER2 in resected gastric cancer: Is there prognostic value?

BACKGROUND AND OBJECTIVES

The role of HER2 in patients with early stage/resected gastric cancer is controversial. This study investigates the prevalence and prognostic value of HER2 in patients undergoing curative intent resection for gastric adenocarcinoma.

METHODS

HER2 status was evaluated in 111 patients with gastric adenocarcinoma treated surgically between 1/00 and 6/11 with tissue available for analysis. Immunohistochemistry (IHC) for HER2 was graded by two blinded pathologists. IHC was scored as 0+/1+: negative, 2+: equivocal, and 3+: positive. Fluorescence in situ hybridization (FISH) for HER2 was performed on equivocal (2+) samples, and in cases of pathologist disagreement.

RESULTS

HER2 expression as measured by IHC was negative in 61 (55%), equivocal in 37 (33.3%), and positive in 13 (11.7%) cases. FISH was positive in 8 of 37 samples tested, for a total of 21 HER2-positive cases (18.9%, 95% CI 11.6-26.2%). Patients with HER2-positive tumors were less likely to have signet ring cell features (23.8% vs. 53.9%, P = 0.008). HER2 status was not associated with tumor size, location, perineural or lymphovascular invasion, margin status, nodal metastasis, or stage (P > 0.05). HER2 status was not associated with OS (P = 0.385).

CONCLUSIONS

HER2 amplification/over-expression is present in patients with resected gastric adenocarcinoma, but is not associated with the presence of adverse prognostic factors. Our results suggest HER2 is not prognostic for patients with resected gastric adenocarcinoma.

Comprehensive genomic meta-analysis identifies intra-tumoural stroma as a predictor of survival in patients with gastric cancer

OBJECTIVE

Gastric adenocarcinoma (gastric cancer, GC) is a major cause of global cancer mortality. Identifying molecular programmes contributing to GC patient survival may improve our understanding of GC pathogenesis, highlight new prognostic factors and reveal novel therapeutic targets. The authors aimed to produce a comprehensive inventory of gene expression programmes expressed in primary GCs, and to identify those expression programmes significantly associated with patient survival.

DESIGN

Using a network-modelling approach, the authors performed a large-scale meta-analysis of GC transcriptome data integrating 940 gastric transcriptomes from multiple independent patient cohorts. The authors analysed a training set of 428 GCs and 163 non-malignant gastric samples, and a validation set of 288 GCs and 61 non-malignant gastric samples.

RESULTS

The authors identified 178 gene expression programmes ('modules') expressed in primary GCs, which were associated with distinct biological processes, chromosomal location patterns, cis-regulatory motifs and clinicopathological parameters. Expression of a transforming growth factor β (TGF-β) signalling associated 'super-module' of stroma-related genes consistently predicted patient survival in multiple GC validation cohorts. The proportion of intra-tumoural stroma, quantified by morphometry in tissue sections from gastrectomy specimens, was also significantly associated with stromal super-module expression and GC patient survival.

CONCLUSION

Stromal gene expression predicts GC patient survival in multiple independent cohorts, and may be closely related to the intra-tumoural stroma proportion, a specific morphological GC phenotype. These findings suggest that therapeutic approaches targeting the GC stroma may merit evaluation.

Perioperative chemotherapy for resectable gastroesophageal cancer: a single-center experience

BACKGROUNDS

Multimodal treatment for locally advanced gastric cancer has been reported to improve disease-free survival when compared to surgery alone. We aimed to clarify the efficacy and safety of perioperative chemotherapy for locally advanced gastric cancer patients treated in daily clinical practice.

METHODS

Patients diagnosed with locally advanced gastric cancer were treated with perioperative chemotherapy and surgery. The primary end point was the complete resection (R0) rate. Secondary end points were disease-free survival (DFS), overall survival (OS), toxicity, radiological response rate, pathological response rate and downstaging rate. We also looked for prognostic and predictive factors for DFS, OS, pathological complete response and the R0 rate.

RESULTS

Forty patients were found eligible for this retrospective analysis. At diagnosis, 52.5% of patients were classified as stage II and 47.5% were stage III. Forty percent of patients completed three preoperative cycles and three postoperative cycles. A tolerable toxicity related to chemotherapy was found. Thirty-nine patients underwent surgery: 80% reached a complete resection (R0), down-staging was detected in 57.5% and 17.5% had a pathologically complete response. The median time of disease-free survival was 34.05 months (95%CI 25.6-42.4), and the median time of overall survival was 39.01 months (95%CI 30.8-47.1). We found that the presence of comorbidities were independent predictive factors for the pathologic response, while the chemotherapy schedule and the clinical response could independently predict a complete resection.

CONCLUSIONS

Our results support that perioperative chemotherapy for locally advanced gastric cancer can be safely delivered in daily clinical practice, obtaining an improvement of the pathologic response and the complete resection of gastric cancer.

Enhanced RegIV expression predicts the intrinsic 5-fluorouracil (5-FU) resistance in advanced gastric cancer

AIM

RegIV, a member of the Regenerating (REG) gene family, may be a marker for the prediction of resistance to 5-fluorouracil (5-FU)-based chemotherapy. However, the relationship between the intrinsic drug resistance of gastric cancer (GC) cells to 5-FU used alone (single FU) or in multidrug therapeutic regimens (5-FU combinations) and RegIV expression has not been investigated.

METHODS

The patient cohort comprised 45 patients with primary GC. The chemoresistance of GC cells to therapeutic regimens consisting of single 5-FU or FU combinations was investigated using the ATP-tumor chemosensitivity assay. The level of RegIV mRNA transcripts was determined by real-time reverse transcriptase-PCR. RegIV expression was evaluated as a novel predictive biomarker for the intrinsic drug resistance of primary GC cells to single 5-FU or 5-FU combinations.

RESULTS

Upregulation of RegIV mRNA transcripts was observed in 36 of the 45 tumor specimens and was positively correlated with the invasive depth of the tumor cells (p = 0.000), the clinical stages (p = 0.000) and the in vitro intrinsic drug resistance of primary GC cells to 5-FU (p = 0.000) or 5-FU combinations.

CONCLUSION

RegIV mRNA transcript level was strongly associated with the intrinsic resistance of GC cells to single 5-FU or 5-FU combinations, suggesting that RegIV may play an important role in the intrinsic resistance of GC cells to 5-FU and that targeted therapy against the RegIV gene could be applied to overcome 5-FU resistance in the treatment of GC.

Role of repeat staging laparoscopy in locoregionally advanced gastric or gastroesophageal cancer after neoadjuvant therapy

INTRODUCTION

Staging laparoscopy (SL) can identify occult, subradiographic metastatic (M1) disease in patients with gastric or gastroesophageal (G/GEJ) cancer who are unlikely to benefit from gastrectomy. The purpose of this study is to determine the yield of repeat SL following neoadjuvant therapy for G/GEJ adenocarcinoma after initial negative pretreatment SL.

METHODS

Retrospective review of a prospective database identified patients with locoregionally advanced (T3-4Nany or TanyN+) G/GEJ adenocarcinoma who underwent pretreatment SL. The yield of repeat SL following neoadjuvant therapy was determined.

RESULTS

From 1994 to 2010, 276 patients with locoregionally advanced G/GEJ adenocarcinoma were identified, of whom 244 proceeded to operation after neoadjuvant therapy, at a median time of 105 days. One hundred sixty-four patients (67 %) underwent repeat SL, and 80 patients (33 %) proceeded directly to laparotomy. Occult M1 disease was identified in 12 (7.3 %) and 6 (7.5 %) patients, respectively. In the repeat SL cohort, M1 disease was identified at laparoscopy in nine patients (5.5 %). M1 disease not identified by laparoscopy was discovered at laparotomy in three patients (1.8 %). The median follow-up for the study population was 31 months. For patients with M1 disease, median overall survival was 15 months, versus 41 months for patients resected without M1 disease (p < 0.0001).

CONCLUSIONS

Occult, subradiographic M1 disease develops in approximately 7 % of patients following neoadjuvant therapy for locoregionally advanced G/GEJ adenocarcinoma. These patients have poor prognosis, and repeat SL can be a valuable tool in selecting patients with locoregionally advanced G/GEJ tumors for potentially curative resection after neoadjuvant therapy.