Nodal dissection for patients with gastric cancer: a randomised controlled trial

Immune microenvironment of tumor-draining lymph nodes: insights for immunotherapy

Tumor-draining lymph nodes (TDLNs) play a crucial role in modulating tumor immune responses and influencing the efficacy of immunotherapy. However, our current understanding of the microenvironment within these lymph nodes remains limited. Tumors not only impair the anti-tumor activity of CD8+ T cells by creating an immunosuppressive microenvironment, but they also facilitate immune evasion and promote metastasis by altering the structure and function of TDLNs. Research has shown that tumor-specific memory CD8+ T cells (TTSM) within TDLNs are essential for the efficacy of immune checkpoint inhibitors, such as PD-1/PD-L1 blockers. Moreover, the abnormal structure of TDLNs, along with the presence of immunosuppressive cells-such as regulatory T cells (Tregs), regulatory B cells (Bregs), and immunosuppressive dendritic cells (DCs)-contributes to tumor-mediated immune evasion. Therefore, gaining a deeper understanding of the immune microenvironment within TDLNs is essential for improving the effectiveness of immunotherapies and developing novel therapeutic strategies. This review explores various TDLN-based therapeutic strategies, addressing the controversies surrounding lymph node dissection, the use of TDLNs as a source of tumor-infiltrating lymphocytes (TILs) for therapy, targeting immunosuppressive cells within TDLNs, and methods to reverse the structural abnormalities of TDLNs. These strategies offer valuable insights and potential directions for advancing tumor immunotherapy.

Prime suspect or collective responsibility: Impact of specific lymph node station dissection on short- and long-term outcomes among locally advanced gastric cancer patients after neoadjuvant chemotherapy

BACKGROUND

Lymphatic route is the main pathway for gastric cancer (GC) spread, and lymph node (LN) involvement is a major prognostic factor after curative resection. The aim of this study was to assess the outcomes of specific LN station dissection.

METHODS

Patients with locally advanced (cT2-4N0-3M0) GC who underwent multimodal treatment between 2013 and 2023 were included in the study. Patients who had not undergone gastrectomy, had early (cT1) or metastatic GC, who had undergone multiorgan resections, palliative care, had died before the end of curative-intent planned treatment, or had incomplete clinical or pathological information were excluded. The primary endpoint was the development of serious complications, and the secondary outcome was OS.

RESULTS

Mulivariable analysis revealed, that among patients who received neoadjuvant chemotherapy (NAC), it was observed that station 10 lymphadenectomy was associated with a higher risk of serious postoperative complications. (27.6 % vs 8.7 %; OR = 3.28) Among the no-NAC group, it was observed that station 13 lymphadenectomy was associated with a higher risk of serious postoperative complications. (57.1 % vs 13.2 %; OR = 6.96). Among the NAC group, a lower risk of death was observed in patients with station 8 (HR = 0.53) or 11 lymphadenectomy (HR = 0.53).

CONCLUSION

While D2 lymphadenectomy remains crucial, particularly in in high-volume, experienced GC centers, the necessity of a more extensive D2+ lymphadenectomy is not supported by our findings. Moreover, we aimed to highlight the importance of tailored surgical approaches and emphasize the significance of LN station dissection in influencing both short-term complications and long-term survival outcomes.

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

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

Predictive value of enhanced CT and pathological indicators in lymph node metastasis in patients with gastric cancer based on GEE model

OBJECTIVES

A predictive model was developed based on enhanced computed tomography (CT), laboratory test results, and pathological indicators to achieve the convenient and effective prediction of single lymph node metastasis (LNM) in gastric cancer.

METHODS

Sixty-six consecutive patients (235 regional lymph nodes) with pathologically confirmed gastric cancer who underwent surgery at our hospital between December 2020 and November 2021 were retrospectively reviewed. They were randomly allocated to training (n = 38, number of lymph nodes = 119) and validation (n = 28, number of lymph nodes = 116) datasets. The clinical data, laboratory test results, enhanced CT characteristics, and pathological indicators from gastroscopy-guided needle biopsies were obtained. Multivariable logistic regression with generalised estimation equations (GEEs) was used to develop a predictive model for LNM in gastric cancer. The predictive performance of the model developed using the training and validation datasets was validated using receiver operating characteristic curves.

RESULTS

Lymph node enhancement pattern, Ki67 level, and lymph node long-axis diameter were independent predictors of LNM in gastric cancer (p < 0.01). The GEE-logistic model was associated with LNM (p = 0.001). The area under the curve and accuracy of the model, with 95% confidence intervals, were 0.944 (0.890-0.998) and 0.897 (0.813-0.952), respectively, in the training dataset and 0.836 (0.751-0.921) and 0.798 (0.699-0.876), respectively, in the validation dataset.

CONCLUSION

The predictive model constructed based on lymph node enhancement pattern, Ki67 level, and lymph node long-axis diameter exhibited good performance in predicting LNM in gastric cancer and should aid the lymph node staging of gastric cancer and clinical decision-making.

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

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

Revolutionizing T3-4N0-2M0 gastric cancer staging with an innovative pathologic N classification system

BACKGROUND

The current pathologic N (pN) classification exhibits limitations in the prognostic stratification of patients with pT3-4N0-2M0 gastric cancer (GC). Therefore, this study aimed to develop and validate a new lymph nodal staging method based on the number of examined lymph nodes (ELNs) and lymph node ratio (LNR).

METHODS

Data from 7883 patients with pT3-4N0-2M0 GC were collected from the Surveillance, Epidemiology, and End Results (SEER) database and Zhejiang Cancer Provincial Hospital. Optimal cutoff values for ELNs and LNR were determined using X-tile software. Kaplan-Meier methods, Log-rank tests, and Cox regression analyses were employed in this study. Patients were categorized into 3 new pN stages: new pN0 (pN0 with ELNs of >16), new pN1 (pN0 with ELNs of ≤16 or pN1-2 with LNR of ≤0.15), and new pN2 (pN1-2 with LNR of >0.15). The prognostic predictive power of both current and new pN staging was evaluated using the Akaike information criterion (AIC), Bayesian information criterion, concordance index (C-index), and receiver operating characteristic curve.

RESULTS

The new pN classification exhibited excellent performance in Kaplan-Meier survival analysis. After adjusting for confounding factors, the new pN staging emerged as an independent prognostic indicator in patients with GC. In the SEER cohort, the new pN staging demonstrated enhanced prognostic prediction accuracy over the American Joint Committee on Cancer pN staging (AIC: 75578.85 vs 75755.06; C-index: 0.642 vs 0.630; P < .001). Similar findings were validated in the Chinese cohort.

CONCLUSION

This study developed and validated an improved pN classification for patients with pT3-4N0-2M0 GC. Surgeons should consider ELNs and LNR when assessing postoperative prognosis in patients with GC.

Let it be: Preserving tumor-draining lymph nodes in the era of immuno-oncology

Solid cancers often progress via metastasis to lymph nodes. Consequently, lymphadenectomy is central to stage cancers and eradicates disease spread. However, mounting evidence suggests that cancer immunotherapies drive antitumor immune responses within lymph nodes. This implies that immunotherapy, delivered with standard oncologic therapies, may require specific treatment sequencing to initiate immunosurveillance and affect primary tumor responses. As supported by recent preclinical and clinical studies, lymphatic-preserving strategies may offer the best promise for driving the next generation of breakthrough immunotherapy approaches.

Dysregulation of autophagy in gastric carcinoma: Pathways to tumor progression and resistance to therapy

The considerable death rates and lack of symptoms in early stages of gastric cancer (GC) make it a major health problem worldwide. One of the most prominent risk factors is infection with Helicobacter pylori. Many biological processes, including those linked with cell death, are disrupted in GC. The cellular "self-digestion" mechanism necessary for regular balance maintenance, autophagy, is at the center of this disturbance. Misregulation of autophagy, however, plays a role in the development of GC. In this review, we will examine how autophagy interacts with other cell death processes, such as apoptosis and ferroptosis, and how it affects the progression of GC. In addition to wonderful its role in the epithelial-mesenchymal transition, it is engaged in GC metastasis. The role of autophagy in GC in promoting drug resistance stands out. There is growing interest in modulating autophagy for GC treatment, with research focusing on natural compounds, small-molecule inhibitors, and nanoparticles. These approaches could lead to breakthroughs in GC therapy, offering new hope in the fight against this challenging disease.

Survival trends in gastric cancer in Brazil: real-life data from a large cancer center

Background

Gastric cancer (GC) is the fourth leading cause of cancer deaths globally. There is a paucity of real-life data on GC in Brazil. Our study aimed to evaluate survival trends in gastric adenocarcinoma (GA) in a large cancer center in Brazil during 2000-2017.

Methods

Based on our Hospital Cancer Registry Database, all individuals diagnosed with GA between 2000 and 2017, and treated at A.C. Camargo Cancer Center, were retrospectively included. The primary objectives were to describe the patient demographics, clinicopathological characteristics, treatment modalities and survival trends during four separate periods of diagnosis (2000-2004; 2005-2009; 2010-2014 and 2015-2017). χ2 test was performed between two specified periods (2000-2004 and 2015-2017) to compare categorical variables. Overall survival (OS) curves were stratified by four separate periods and compared with log-rank tests.

Results

This analysis included 1,406 individuals. Across all periods, most patients were men aged 50-69 and presented with Lauren's intestinal subtype. The frequency of stage IV disease significantly decreased between 2000-2004 and 2015-2017 (43.6% to 32.8%, p < 0.001). In contrast, we observed a rise in stage II (9.4% to 24.8%, p < 0.001) in the same comparison. We noticed an increased utilization of a combined approach involving chemotherapy and surgery (12% in 2000-2004 and 36.3% in 2015-2017, p < 0.001). The predicted 5-year OS of patients with GA in 2000-2004 was 27.8%, which increased to 53.9% in 2015-2017 (p < 0.001).

Conclusion

Our retrospective cohort showed an upward trend in survival rates during the period. We observed that 5-year OS almost doubled among men and women during 2000-2017.

Mini Abstract

The present retrospective cohort showed an upward trend in survival rates during the period from 2000 to 2017, in which the OS almost doubled among men and women.

Optimal lymph node dissection for gastric cancer: a narrative review

The management of gastric cancer has long been debated, particularly the extent of lymph node (LN) dissection required during curative surgery. LN invasion stands out as the most critical prognostic factor in gastric cancer. Historically, Japanese academic societies were the pioneers in defining a classification system for regional gastric LN stations, numbering them from 1 to 16. This classification was later used to differentiate between different types of LN dissection, such as D1, D2 and D3. However, these definitions were often considered too complex to be universally adopted, resulting in wide variations in recommendations from one country to another and making it difficult to compare published studies. In addition, the optimal extent of LN dissection remains uncertain, with initially recommended dissections being extensive but associated with significant morbidity without a clear survival benefit. The aim of this review is to make a case for extending LN dissection based on the existing literature, which includes a comprehensive examination of the current definitions of lymphadenectomy and an analysis of the results of all randomised controlled trials evaluating morbidity, mortality and long-term survival associated with different types of LN dissection. Finally, we provide a summary of the various recommendations issued by organizations such as the Japanese Gastric Research Association, the National Comprehensive Cancer Network, the European Society for Medical Oncology, and the French National Thesaurus of Digestive Oncology.

Prognostic Value of Postoperative Complication for Gastric Cancer

Background: The incidence of complications in gastric cancer (GC) patients after surgery was increasing, and it was not clear whether postoperative complications would have an impact on prognosis. The current study attempted to investigate the role of postoperative complication for prognosis on GC patients undergoing radical resection. Materials and Methods: Eligible studies were searched in three databases, including PubMed, Embase, and the Cochrane Library, in accordance with the searching strategy on September 4th, 2022. The survival values were most concerned; then, hazard ratios (HRs) and 95% confidence intervals (CIs) were pooled up. All prognostic values, including overall survival (OS), disease-free survival (DFS), disease-specific survival (DSS), and recurrence-free survival (RFS), were allowed. Subgroup analysis based on complication types was used for further in-depth research. Results: A total of 29 studies involving 33,858 patients were included in this study. Intra-abdominal abscess (19.4%) was the most common complications in the included studies, followed by anastomotic leakage (17.0%) and pneumonia (16.4%). There were 23, 4, 6, and 10 studies that reported OS, DFS, DSS, and RFS, respectively. After analysis, postoperative complication was found to be an independent prognostic factor for OS (HR = 1.52, I2 = 1.14%, 95% CI = 1.42-1.61, P = .00), DFS (HR = 1.71, I2 = 0.00%,95% CI = 1.44-1.98, P < .05), DSS (HR = 1.60, I2 = 54.58%, 95% CI = 1.26-1.93, P < .1), and RFS (HR = 1.26, I2 = 0.00%, 95% CI = 1.11-1.41, P < .05). Subgroup analysis found that noninfectious complication was not significantly associated with OS (HR = 1.39, I2 = 0.00%, 95% CI = 0.96-1.82, P > .05). Conclusion: Surgeons needed to pay more attention to GC patients who developed postoperative complications, especially infectious complications, and take proactive management to improve the prognosis.

A Comparative Analysis of Laparoscopic Gastrectomy Versus Laparoscopic-Assisted Gastrectomy: The Overall and Disease-Free Survival

Gastric cancer remains a significant global health challenge with varied survival rates, emphasizing the need for research into effective surgical treatments. In this retrospective study, we compared the 72-month overall and disease-free survival between laparoscopic gastrectomy (LG) and laparoscopic-assisted gastrectomy (AG) in a cohort of 139 patients treated for gastric cancer. The analysis revealed that patients undergoing LG exhibited a significantly higher overall survival rate at 72 months compared to those undergoing AG. Although disease-free survival rates were comparable between the two groups, LG showed a marginal advantage. Subgroup analyses based on the type of gastrectomy and anastomosis demonstrated varied survival probabilities, with laparoscopic-assisted partial gastrectomy yielding the most favorable outcomes. These results highlight the importance of the choice of surgical technique in influencing survival outcomes in gastric cancer.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A web-based prediction model for long-term cancer-specific survival of middle-aged patients with early-stage gastric cancer: a multi-institutional retrospective study

BACKGROUND

This study constructed and validated a prognostic model to evaluate long-term cancer-specific survival (CSS) in middle-aged patients with early gastric cancer (EGC).

METHODS

We extracted clinicopathological data from relevant patients between 2004 and 2015 from Surveillance, Epidemiology, and End Results (SEER) database, and randomly divided the patients into a training group (N = 688) and a validation group (N = 292). In addition, 102 Chinese patients were enrolled for external validation. Univariate and multivariate Cox regression models were used to screen for independent prognostic factors, and a nomogram was constructed to predict CSS. We used the concordance index (C-index), calibration curve, receiver operating characteristic (ROC) curve, and decision curve analysis (DCA) to evaluate the predictive performance of the model.

RESULTS

Univariate and multivariate COX regression analyses showed that tumor location, differentiation grade, N stage, chemotherapy, and number of regional nodes examined were independent risk factors for prognosis, and these factors were used to construct the nomogram. The C-index of the model in the training cohort, internal validation cohort, and external validation cohort was 0.749 (95% CI 0.699-0.798), 0.744 (95% CI 0.671-0.818), and 0.807 (95% CI 0.721-0.893), respectively. The calibration curve showed that the model had an excellent fit. The DCA curve showed that the model had good predictive performance and practical clinical value.

CONCLUSION

This study developed and validated a new nomogram to predict CSS in middle-aged patients with EGC. The prediction model has unique and practical value and can help doctors carry out individualized treatment and judge prognosis.

Lymph nodes: at the intersection of cancer treatment and progression

Metastasis to lymph nodes (LNs) is a common feature of disease progression in most solid organ malignancies. Consequently, LN biopsy and lymphadenectomy are common clinical practices, not only because of their diagnostic utility but also as a means of deterring further metastatic spread. LN metastases have the potential to seed additional tissues and can induce metastatic tolerance, a process by which tumor-specific immune tolerance in LNs promotes further disease progression. Nonetheless, phylogenetic studies have revealed that distant metastases are not necessarily derived from nodal metastases. Furthermore, immunotherapy efficacy is increasingly being attributed to initiation of systemic immune responses within LNs. We argue that lymphadenectomy and nodal irradiation should be approached with caution, particularly in patients receiving immunotherapy.

Safety and efficacy of indocyanine green near-infrared fluorescent imaging-guided lymph node dissection during robotic gastrectomy for gastric cancer: a systematic review and meta-analysis

BACKGROUND

In Asia, particularly, robotic gastrectomy has grown in popularity as a treatment for stomach cancer. Indocyanine green (ICG) and near-infrared (NIR) fluorescent imaging technology has been reported for robotic gastrectomy. However, the clinical value still should be further evaluated. In this meta-analysis, we investigated the safety and efficacy of ICG near-infrared fluorescent imaging-guided lymph node (LN) dissection during robotic gastrectomy.

MATERIAL AND METHODS

Through July 2022, systematic searches of PubMed, Embase, Web of Science, and the Cochrane Library were conducted to find studies comparing ICG fluorescence imaging with conventional treatment in patients with gastric cancer. The current meta-analysis was performed according to the preferred reporting items for systematic review and meta-analysis guidelines. A pooled analysis was performed for the available data regarding the number of lymph node dissections, other operative outcomes and postoperative complications. R studio software 4.2.2 was used for this meta-analysis.

RESULTS

This analysis includes five studies with a total of 312 gastric cancer patients (128 in the ICG group and 184 in the non-ICG group). In this meta-analysis, the number of retrieved LNs in the ICG group was significantly higher (weighted mean difference [WMD] = 8.80, 95% confidence intervals [CI]: 4.37-13.22, p < 0.05) than that in the non-ICG group with moderate heterogeneity (p < 0.0001, I2=53.3%). Intraoperative blood loss and postoperative complications were all comparable and without significant heterogeneity. Additionally, ICG near-infrared fluorescent imaging was associated with a reduced operative time (WMD= -11.85, 95% CI: -22.40 to -1.30, p < 0.05) with low heterogeneity (p = 0.027, I2= 2.1%).

CONCLUSIONS

ICG near-infrared fluorescent imaging-guided lymphadenectomy was considered to be safe and effective in robotic gastrectomy. ICG was used to increase the number of LNs harvested while reducing operative time without increasing intraoperative blood loss or postoperative complications.

Current standards of lymphadenectomy in gastric cancer

Gastric cancer remains the 5th most common cancer and the 3rd most common cause of cancer mortality. Most patients diagnosed with gastric cancer still have a poor prognosis due to its advanced presentation at diagnosis, even in countries with developed screening programs. Surgery is the cornerstone of the treatment for gastric cancer, often combined with perioperative chemotherapy. Lymph node dissection is a crucial component of the surgical treatment of gastric cancer. D1 lymphadenectomy is currently recommended for early stage tumors. The extent of lymphadenectomy in advanced gastric cancer, however, is still a matter of debate between Eastern and Western surgeons. Although a D2 dissection is the current standard recommended by most guidelines, there might be a place for more limited dissections such as D1 + in selected cases. This evidence-based review will help defining the optimal lymphadenectomy for patients with gastric cancer.

Lymph node metastasis in cancer progression: molecular mechanisms, clinical significance and therapeutic interventions

Lymph nodes (LNs) are important hubs for metastatic cell arrest and growth, immune modulation, and secondary dissemination to distant sites through a series of mechanisms, and it has been proved that lymph node metastasis (LNM) is an essential prognostic indicator in many different types of cancer. Therefore, it is important for oncologists to understand the mechanisms of tumor cells to metastasize to LNs, as well as how LNM affects the prognosis and therapy of patients with cancer in order to provide patients with accurate disease assessment and effective treatment strategies. In recent years, with the updates in both basic and clinical studies on LNM and the application of advanced medical technologies, much progress has been made in the understanding of the mechanisms of LNM and the strategies for diagnosis and treatment of LNM. In this review, current knowledge of the anatomical and physiological characteristics of LNs, as well as the molecular mechanisms of LNM, are described. The clinical significance of LNM in different anatomical sites is summarized, including the roles of LNM playing in staging, prognostic prediction, and treatment selection for patients with various types of cancers. And the novel exploration and academic disputes of strategies for recognition, diagnosis, and therapeutic interventions of metastatic LNs are also discussed.

Osteopontin promotes gastric cancer progression via phosphatidylinositol-3-kinase/protein kinase B/mammalian target of rapamycin signaling pathway

BACKGROUND

Gastric cancer (GC) is one of the most common malignant tumors. Osteopontin (OPN) is thought to be closely related to the occurrence, metastasis and prognosis of many types of tumors.

AIM

To investigate the effects of OPN on the proliferation, invasion and migration of GC cells and its possible mechanism.

METHODS

The mRNA and protein expression of OPN in the GC cells were analyzed by real-time quantitative-reverse transcription polymerase chain reaction and western blotting, and observe the effect of varying degree expression OPN on the proliferation and other behaviors of GC. Next, the effects of OPN knockdown on GC cells migration and invasion were examined. The short hairpin RNA (shRNA) and negative control shRNA targeting OPN-shRNA were transfected into the cells according to the manufacturer's instructions. Non transfected cells were classified as control in the identical transfecting process. 24 h after RNA transfection cell proliferation activity was detected by 3-(4,5)-dimethylthiahiazo (-z-y1)-3,5-di-phenytetrazoliumromide assay, and cell invasiveness and migration were detected by Trans well assay. Meanwhile, the expression of protein kinase B (AKT), matrix metalloproteinase 2 (MMP-2) and vascular endothelial growth factor (VEGF) in the human GC cell lines was detected by reverse transcription polymerase chain reaction and western blotting.

RESULTS

The results of this study revealed that OPN mRNA and protein expression levels were highly expressed in SGC-7901 cells. OPN knockdown by specific shRNA noticeably reduced the capabilities of proliferation, invasion and migration of SGC-7901 cells. Moreover, in the experiments of investigating the underlying mechanism, results showed that OPN knockdown could down-regulated the expression of MMP-2 and VEGF, it also decreased the phosphorylation of AKT. Meanwhile, the protein expression levels of MMP-2, VEGF and phosphorylated AKT was noticeable lower than that in control group in the GC cells after they were added to phosphatidylinositol-3-kinase (PI3K) inhibitor (LY294002).

CONCLUSION

These results suggested that OPN though PI3K/AKT/mammalian target of rapamycin signal pathway to up-regulate MMP-2 and VEGF expression, which contribute SGC-7901 cells to proliferation, invasion and migration. Thus, our results demonstrate that OPN may serve as a novel prognostic biomarkers as well as a potential therapeutic targets for GC.

Comparison of Surgical and Oncological Outcomes of Laparoscopic and Open Gastrectomy for Pathologically Serosa-Invasive (pT4a) Advanced Gastric Cancer-Retrospective Propensity Score-Matched Analysis

Background: We aimed to clarify the operative feasibility and oncological efficacy of a laparoscopic gastrectomy (LG) for pT4a gastric cancer through comparison with open gastrectomy (OG). Materials and Methods: We compared surgical and oncological outcomes in 178 patients with pT4a gastric cancer who underwent LG or OG between 2002 and 2016; the background was adjusted using propensity score matching. Results: After score matching, 45 patients were included in each group. The LG group had a significantly longer operation time (277 minutes versus 175 minutes, P < .001) and lower estimated blood loss (50 mL versus 280 mL, P < .001). The total number of dissected lymph nodes did not differ between groups (46 versus 38, P = .119); however, the number of dissected suprapancreatic lymph nodes was significantly higher in the LG group (11 versus 7.5, P = .011). Postoperative morbidity rates did not differ between groups. Postoperative hospitalization was significantly shorter in the LG group (7 days versus 13 days, P < .01), whereas overall survival, disease-free survival, and cancer recurrence rates and patterns were similar between groups. Conclusions: LG for pT4a gastric cancer has feasible and acceptable outcomes compared with OG.

Efficacy of Lymph Node Location-Number Hybrid Staging System on the Prognosis of Gastric Cancer Patients

BACKGROUND

Lymph node metastasis location and number significantly affects the prognosis of patients with gastric cancer (GC). This study was designed to examine a new lymph node hybrid staging (hN) system to increase the predictive ability for patients with GC.

METHODS

This study analyzed the gastrointestinal treatment of GC at the Harbin Medical University Cancer Hospital from January 2011 to December 2016, and selected 2598 patients from 2011 to 2015 as the training cohort (hN) and 756 patients from 2016 as the validation cohort (2016-hN). The study utilized the receiver operating characteristic curve (ROC), c-index, and decision curve analysis (DCA) to compare the prognostic performance of the hN with the 8th edition of AJCC pathological lymph node (pN) staging for GC patients.

RESULTS

The ROC verification of the training cohort and validation cohort based on each hN staging and pN staging showed that for each N staging, the hN staging had a training cohort with an AUC of 0.752 (0.733, 0.772) and a validation cohort with an AUC of 0.812 (0.780, 0.845). In the pN staging, the training cohort had an AUC of 0.728 (0.708, 0.749), and the validation cohort had an AUC of 0.784 (0.754, 0.824). c-Index and DCA also showed that hN staging had a higher prognostic ability than pN staging, which was confirmed in the training cohort and the verification cohort, respectively.

CONCLUSION

Lymph node location-number hybrid staging can significantly improve the prognosis of patients with GC.

Intraoperative performance and outcomes of robotic and laparoscopic total gastrectomy for gastric cancer: A high-volume center retrospective propensity score matching study

BACKGROUND

Studies on robotic total gastrectomy (RTG) are currently limited. This study aimed to compare the intraoperative performance as well as short- and long-term outcomes of RTG and laparoscopic total gastrectomy (LTG).

METHODS

A total of 969 patients underwent robotic (n = 161) or laparoscopic (n = 636) total gastrectomy between October 2014 and October 2021. The two groups of patients were matched 1:3 using the propensity score matching (PSM) method. The intraoperative performance as well as short- and long-term outcomes of the robotic (n = 147) and the laparoscopic (n = 371) groups were compared.

RESULTS

After matching, the estimated intraoperative blood loss was lower (80.51 ± 68.77 vs. 89.89 ± 66.12, p = 0.008), and the total number of lymph node dissections was higher (34.74 ± 12.44 vs. 29.83 ± 12.22, p < 0.001) in the RTG group compared with the LTG group. More lymph node dissections at the upper edge of the pancreas were performed in the RTG group than in the LTG (12.59 ± 4.18 vs. 10.33 ± 4.58, p = 0.001). Additionally, postoperative recovery indicators and laboratory data were greater in the RTG group than those in the LTG group, while postoperative complications were comparable between the two groups (19.0% vs. 18.9%, p = 0.962). For overweight or obese patients with body mass indexes (BMIs) ≥25, certain clinical outcomes of the RTG remained advantageous, and no significant differences in three-year overall survival (OS) or relapse-free survival (RFS) were observed.

CONCLUSIONS

Robotic total gastrectomy demonstrated better intraoperative performance, could improve the short-term clinical outcomes of patients, and was more conducive to patient recovery. However, the long-term efficacies of the two approaches were similar. Robotic surgical systems may reduce surgical stress responses in patients, allowing them to receive postoperative chemotherapy sooner.

Current standards of surgical management of gastric cancer: an appraisal

PURPOSE

Gastric cancer (GC) is the fifth most common malignancy worldwide and portends a grim prognosis due to a lack of appreciable improvement in 5-year survival. We aimed to analyze the available literature and summarize the current standards of surgical care for curative and palliative intent treatment of GC.

METHODS

We conducted a systematic search on the PubMed database for studies on the management of GC.

RESULTS

Endoscopic resection is an acceptable treatment option for T1a tumors. The role of optimal resection margin for GC remains unclear. D2 lymph node dissection remains the standard of care with splenectomy needed selectively for splenic hilum involvement. A distal pancreatic resection should be avoided. The advantage of bursectomy and omentectomy in GC surgery is not clear. Multi-visceral resection may be considered for locally advanced GC in carefully selected patients. Minimally invasive approaches are non-inferior to open surgery. Surgery should be abandoned prior even in metastatic GC within the frame of multimodal therapy approach.

CONCLUSION

Various trials have conclusively shown improved patient outcomes when well-established surgical standards are followed.

Extended Lymphadenectomy for Gastric Cancer in the Neoadjuvant Era: Current Status, Clinical Implications and Contentious Issues

Despite its decreasing incidence, gastric cancer remains an important global healthcare problem due to its overall high prevalence and high mortality rate. Since the MAGIC and FNLCC/FFCD trials, the neoadjuvant chemotherapy has been recommended throughout Europe in gastric cancer. Potential benefits of preoperative treatments include a higher rate of R0 resection achieved by downstaging the primary tumor, a likely effect on micrometastases and isolated tumor cells in the lymph nodes, and, as a result, improved cancer-related survival. Nevertheless, distortion of anatomical planes of dissection, interstitial fibrosis, and sclerotic tissue changes may increase surgical difficulty. The collection of at least twenty-five lymph nodes after neoadjuvant therapy would seem to ensure removal of undetectable node metastasis and reduce the likelihood of locoregional recurrence. It is not what you take but what you leave behind that defines survival. Therefore, para-aortic lymph node dissection is safe and effective after neoadjuvant chemotherapy, in both therapeutic and prophylactic settings. In this review, the efficacy of adequate lymph node dissection, also in a neoadjuvant setting, has been investigated in the key studies conducted to date on the topic.

Clinical Management of Gastric Cancer Treatment Regimens

Gastric cancer is the fifth most common cancer and the fourth leading cause of cancer-associated death in the world. Endoscopic resection can be the treatment in selected cases of very early gastric cancer. Surgery is recommended for tumors that do not meet the criteria for endoscopic resection or for tumors with lymph node invasion but without distant metastases. Gastrectomy should include D2 lymphadenectomy without splenectomy. Perioperative or adjuvant chemotherapy improves survival and is recommended in locally advanced gastric cancer (>T1 and/or with lymph nodes positive). In locally advanced cancer with microsatellite instability (MSI), immunotherapy should be considered. Advanced unresectable or metastatic gastric cancer has a poor prognosis. The basis of the treatment is cytotoxic chemotherapy, with platinum and fluoropyrimidine doublet in the first line. Targeted therapies can be combined with chemotherapy. Trastuzumab (anti-HER2) is recommended in the first line in HER2-positive cancer. Ramucirumab (anti-VEGFR2) is recommended in the second line, in addition to paclitaxel chemotherapy. Zolbetuximab (anti-Claudine 18.2) should also be considered in the first line in Claudine 18.2-positive cancer. Immunotherapy can also be associated with chemotherapy in the first line of PD-L1-positive cancer. In HER2-positive and PD-L1-positive cancer, adjunction of trastuzumab and immunotherapy should be considered. In advanced and metastatic cancer with microsatellite instability (MSI), immunotherapy should be the first choice depending on its availability. Important progress has been made in recent years in the treatment of gastric cancer, especially due to a better understanding of molecular characteristics and heterogeneity of this disease. New targets and therapeutic approaches are being developed, which will very likely lead to changes in the management of gastric cancer.

Gastric adenocarcinoma burden, trends and survival in Cali, Colombia: A retrospective cohort study

Background

Gastric adenocarcinoma (GA) has changed in recent decades. Cancer estimates are often calculated from population-based cancer registries, which lack valuable information to guide decision-making (clinical outcomes). We describe the trends in clinical practice for GA using a hospital-based cancer registry over a timespan of 15 years.

Methods

A retrospective cohort study was conducted. Data were gathered from adults diagnosed and treated for GA at Fundación Valle del Lili (FVL), between 2000 and 2014, from the hospital's own cancer registry and crossed with Cali's Cancer Registry. Additional data were obtained directly from clinical records, pathology reports and the clinical laboratory. Patients younger than 18 years and those for whom limited information was available in the medical history were excluded. A survival analysis was conducted using Kaplan-Meier method.

Results

A total of 500 patients met eligibility criteria. Median age was 64 years (IQR: 54-74 years), 39.8% were female, 22.2% were at an early stage, 32.2% had a locally advanced disease, and 29% a metastatic disease, 69% had intestinal subtype, 48.6% had a positive H. pylori test, 85.2% had a distal lesion, 62% underwent gastrectomy, 60.6% lymphadenectomy, and 40.6% received chemotherapy. Survival at 5 years for all cases was 39.9% (CI 95% 35.3-44.5). Survival decreased over time in all groups and was lower in age-groups <39 and 60-79 with either locally advanced or metastatic disease. Prognostic factors that were significant in the Cox proportional-hazards model were late stages of the tumor (locally advanced: HR=2.52; metastatic: HR=4.17), diffuse subtype (HR=1.40), gastrectomy (subtotal: HR=0.42; total: 0.44) and palliative chemotherapy (HR=0.61).

Conclusions

The treatment of GA has changed in recent decades. GA survival was associated with clinical staging, diffuse subtype, gastrectomy and palliative chemotherapy. These findings must be interpreted in the context of a hospital-based study.

Indications for Adjuvant Chemotherapy in Stage II Gastric Cancer After D2 Gastrectomy-A Chinese Multicenter Study

BACKGROUND

The benefit of adjuvant chemotherapy (AC) for patients with stage II gastric cancer remains controversial. This study aimed to explore the indications for adjuvant chemotherapy in patients with stage II gastric cancer by constructing an individual prediction model.

PATIENTS AND METHODS

In this Chinese multicenter study, a total of 1012 patients with stage II gastric cancer after D2 radical gastrectomy were retrospectively analyzed. All patients were randomly assigned to a training cohort (n = 674) or a validation cohort (n = 338). A nomogram was constructed according to the training cohort. Concordance index (C-index), the area under the receiver operating characteristic (ROC) curves (AUC), calibration curves, and decision curve analysis (DCA) were applied to evaluate the performance of the nomogram. ROC curves and stratified survival were used to determine the patients' cutoff score for a benefit from adjuvant chemotherapy. An additional 338 patients were used as a validation cohort to validate the feasibility of using this nomogram to guide individualized therapy for patients with stage II gastric cancer.

RESULTS

Univariate and multivariate analyses illustrated that age, sex, tumor location, size, carcinoembryonic antigen (CEA), hemoglobin (HB), and T stage were independent prognostic factors for overall survival (OS), and they were used to establish a nomogram. The cutoff value was determined by ROC curve analysis, and patients were divided into a high-risk group (< 239 points) and a low-risk group (≥ 239 points). There was no significant difference in the OS of low-risk patients in either the training cohort or the validation cohort. However, the OS of high-risk patients in the AC group was better than that of patients in the surgery-only group.

CONCLUSIONS

This prediction model can be applied to guide treatment of patients with stage II gastric cancer. High-risk patients (< 239 points) are likely to benefit from AC after D2 radical gastrectomy.

Metastatic lymph nodes and prognosis assessed by the number of retrieved lymph nodes in gastric cancer

BACKGROUND

The prognostic value of quantitative assessments of the number of retrieved lymph nodes (RLNs) in gastric cancer (GC) patients needs further study.

AIM

To discuss how to obtain a more accurate count of metastatic lymph nodes (MLNs) based on RLNs in different pT stages and then to evaluate patient prognosis.

METHODS

This study retrospectively analyzed patients who underwent GC radical surgery and D2/D2+ LN dissection at the Cancer Hospital of Harbin Medical University from January 2011 to May 2017. Locally weighted smoothing was used to analyze the relationship between RLNs and the number of MLNs. Restricted cubic splines were used to analyze the relationship between RLNs and hazard ratios (HRs), and X-tile was used to determine the optimal cutoff value for RLNs. Patient survival was analyzed with the Kaplan-Meier method and log-rank test. Finally, HRs and 95% confidence intervals were calculated using Cox proportional hazards models to analyze independent risk factors associated with patient outcomes.

RESULTS

A total of 4968 patients were included in the training cohort, and 11154 patients were included in the validation cohort. The smooth curve showed that the number of MLNs increased with an increasing number of RLNs, and a nonlinear relationship between RLNs and HRs was observed. X-tile analysis showed that the optimal number of RLNs for pT1-pT4 stage GC patients was 26, 31, 39, and 45, respectively. A greater number of RLNs can reduce the risk of death in patients with pT1, pT2, and pT4 stage cancers but may not reduce the risk of death in patients with pT3 stage cancer. Multivariate analysis showed that RLNs were an independent risk factor associated with the prognosis of patients with pT1-pT4 stage cancer (P = 0.044, P = 0.037, P = 0.003, P < 0.001).

CONCLUSION

A greater number of RLNs may not benefit the survival of patients with pT3 stage disease but can benefit the survival of patients with pT1, pT2, and pT4 stage disease. For the pT1, pT2, and pT4 stages, it is recommended to retrieve 26, 31 and 45 LNs, respectively.

The Role of Surgery in the Management of Gastric Cancer: State of the Art

Surgery still represents the mainstay of treatment of all stages of gastric cancer (GC). Surgical resections represent potentially curative options in the case of early GC with a low risk of node metastasis. Sentinel lymph node biopsy and indocyanine green fluorescence are novel techniques which may improve the employment of stomach-sparing procedures, ameliorating quality of life without compromising oncological radicality. Nonetheless, the diffusion of these techniques is limited in Western countries. Conversely, radical gastrectomy with extensive lymphadenectomy and multimodal treatment represents a valid option in the case of advanced GC. Differences between Eastern and Western recommendations still exist, and the optimal multimodal strategy is still a matter of investigation. Recent chemotherapy protocols have made surgery available for patients with oligometastatic disease. In this context, intraperitoneal administration of chemotherapy via HIPEC or PIPAC has emerged as an alternative weapon for patients with peritoneal carcinomatosis. In conclusion, the surgical management of GC is still evolving together with the multimodal strategy. It is mandatory for surgeons to be conscious of the current evolution of the surgical management of GC in the era of multidisciplinary and tailored medicine.

Is D2 Lymphadenectomy Necessary in Elderly Gastric Cancer Patients? A Retrospective Study

Objective

We retrospectively analyzed the validity of limited lymphadenectomy (D1 and D1+) in elderly gastric cancer patients.

Summary of background data

According to the aging trend in Japan, patients with gastric cancer are continuing to age. The extent of lymphadenectomy preferable for older patients is unclear.

Methods

The data of 35 and 52 patients ≥80 years old with cT2− or N(+) gastric cancer who underwent gastrectomy with D2 lymphadenectomy and limited lymphadenectomy, respectively, at 2 institutions between 2010 and 2019 were retrospectively reviewed.

Results

The patients who underwent limited lymphadenectomy were older and their Onodera prognostic nutritional indexes were poorer than those who underwent D2 lymphadenectomy, although the differences were not significant. After propensity score matching, 28 patients in each group were analyzed. No significant differences in postoperative complications, initial recurrence sites, or causes of death were observed between the 2 groups except for postoperative respiratory failure, which was more frequent after D2 lymphadenectomy. The median overall survival time after D2 and limited lymphadenectomy was 73.9 and 70.9 months, respectively, with a hazard ratio of 1.32 (P = 0.53).

Conclusions

D1+ or even D1 lymphadenectomy may be acceptable for patients ≥80 years old with advanced gastric cancer.

Signaling pathways and therapeutic interventions in gastric cancer

Gastric cancer (GC) ranks fifth in global cancer diagnosis and fourth in cancer-related death. Despite tremendous progress in diagnosis and therapeutic strategies and significant improvements in patient survival, the low malignancy stage is relatively asymptomatic and many GC cases are diagnosed at advanced stages, which leads to unsatisfactory prognosis and high recurrence rates. With the recent advances in genome analysis, biomarkers have been identified that have clinical importance for GC diagnosis, treatment, and prognosis. Modern molecular classifications have uncovered the vital roles that signaling pathways, including EGFR/HER2, p53, PI3K, immune checkpoint pathways, and cell adhesion signaling molecules, play in GC tumorigenesis, progression, metastasis, and therapeutic responsiveness. These biomarkers and molecular classifications open the way for more precise diagnoses and treatments for GC patients. Nevertheless, the relative significance, temporal activation, interaction with GC risk factors, and crosstalk between these signaling pathways in GC are not well understood. Here, we review the regulatory roles of signaling pathways in GC potential biomarkers, and therapeutic targets with an emphasis on recent discoveries. Current therapies, including signaling-based and immunotherapies exploited in the past decade, and the development of treatment for GC, particularly the challenges in developing precision medications, are discussed. These advances provide a direction for the integration of clinical, molecular, and genomic profiles to improve GC diagnosis and treatments.

Surgical and short-term outcomes in robotic and laparoscopic distal gastrectomy for gastric cancer with enhanced recovery after surgery protocol: A propensity score matching analysis

OBJECTIVE

This study aims to evaluate the short-term surgical outcomes of laparoscopy-assisted distal gastrectomy (LADG) and robot-assisted distal gastrectomy (RADG) for gastric cancer (GC) with enhanced recovery after surgery (ERAS) protocols.

METHODS

We reviewed the medical records of 202 patients undergoing radical distal gastrectomy; among them, 67 cases were assisted through RADG, while 135 cases were assisted through LADG along with ERAS. We retrospectively collected the medical records in succession from a database (January 2016-March 2019). We adopted propensity score matching to compare surgical and short-term outcomes of both groups.

RESULTS

After the successful examination of 134 cases, including 67 receiving RADG and 67 undergoing LADG, the operative times were noted as 5.78 ± 0.96 h for the RADG group and 4.47 ± 1.01 h for the LADG group (P < 0.001). The blood loss was noted as 125.52 ± 101.18 ml in the RADG group and 164.93 ± 109.32 ml in the LADG group (P < 0.05). The shorter time to first flatus was 38.82 ± 10.56 h in the RADG group and 42.88 ± 11.25 h in the LADG group (P < 0.05). In contrast, shorter days of postoperative hospital stay were 5.94 ± 1.89 days in the RADG group and 6.64 ± 1.92 days in the LADG group (P < 0.05). Also, the RADG group (84483.03 ± 9487.37) was much more costly than the LADG group (65258.13 ± 8928.33) (P < 0.001). The postoperative overall complication rates, numbers of dissected lymph nodes, visual analogue scale (VAS), and time to start a liquid diet for the RADG group and the LADG group were similar.

CONCLUSIONS

In this research, we concluded that RADG provides surgical benefits and short-term outcomes compared to LADG for GC with ERAS.

Fifty years of progress in gastric cancer

As with every human malignancy, the diagnosis, staging, and treatment of patients with gastric cancer have undergone enormous evidence-based change over the last 50 years, largely as a result of increasingly rapid developments in technology and science. Some of the changes in clinical practice have derived from prospective randomized controlled trials (RCTs), whereas others have come from study of meticulously maintained prospective databases, which define the disease's natural history over time, and occasionally from in-depth analysis of a single patient with an unexpectedly good or poor outcome. Herein we summarize the more important changes in gastric cancer management and the data supporting those changes.

Determination of the extent of dissection in early gastric cancer based on lymph node station power index

Background

The relative prognostic value of each lymph node (LN) station remains undefined in the treatment of gastric cancer. This study aimed to develop a new method to evaluate LN station ranking and define the optimal extent of lymphadenectomy for early gastric cancer.

Methods

Clinical and histopathological information from patients who underwent curative gastrectomy with lymphadenectomy between 1989 and 2018 was reviewed. The LN station power index (LNPI) of each station was estimated using a LN retrieval frequency and the 5-year overall survival of patients with absence of LN at each station. External validation was conducted to evaluate the relevance of the LNPI.

Results

A training set was developed from examination of 7009 patient records. For most nodal stations, the absence of LN was significantly associated with a poor prognosis. For the perigastric stations, the prognostic value assessed using the LNPI was in the following order: LN 4 (LNPI = 19.68), LN 3 (LNPI = 17.58), LN 6 (LNPI = 15.16), LN 1 (LNPI = 6.71), LN 2 (LNPI = 4.64) and LN 5 (LNPI = 2.86). The value rank of the extra-gastric stations was in the following order: LN 8a (LNPI = 12.93), LN 7 (LNPI = 10.51) and LN 9 (LNPI = 9.70), but the index of LN 12a (LNPI = 4.79) was higher than that of LN 11 (LNPI = 4.78). These trends in the LNPI were similar in the validation patient cohort.

Conclusions

The LNPI is a simple tool to rank the priority of each LN station dissection. The optimal extent of D1 + lymphadenectomy using LNPI was determined to be D1 with LNs 7, 8a and 9.

A good surgical field for para-aortic nodal dissection in gastric cancer by the Cattell-Braasch maneuver

PURPOSE

Gastric cancer patients with para-aortic lymph node metastases may achieve long-term survival with radical gastrectomy and para-aortic lymph nodal dissection (PAND) following neoadjuvant therapy. We introduced the Cattell-Braasch maneuver to facilitate safe and complete PAND for advanced gastric cancer with extensive lymph node metastases.

METHODS

Between January 2014 and March 2020, 7 patients with highly advanced gastric cancer received preoperative chemotherapy followed by radical gastrectomy and PAND using the Cattell-Braasch maneuver. This maneuver consists of mobilization of the right hemi-colon and the total small intestine.

RESULTS

Five patients received preoperative chemotherapy for para-aortic lymph node metastases and 2 for bulky lymph node metastases around the supra-pancreatic area. All patients received S-1 + cisplatin therapy, and one was additionally treated with paclitaxel chemotherapy followed by nivolumab. After chemotherapy, 2 patients with para-aortic lymph node metastases achieved down-staging on imaging tests. Total gastrectomy with PAND by the Cattell-Braasch maneuver was performed on all patients and was accompanied by splenectomy (n = 5) and distal pancreatectomy (n = 1). Pathological assessments revealed that 3 patients had para-aortic lymph node metastases, and the median number of retrieved para-aortic lymph nodes was 16. Three patients without para-aortic lymph node metastasis survived for more than 5 years without recurrence.

CONCLUSION

The Cattell-Braasch maneuver provides a good surgical field and is useful for complete PAND for gastric cancer.

Targeting MET amplification in Gastro-oesophageal (GO) malignancies and overcoming MET inhibitor resistance: challenges and opportunities

INTRODUCTION

MET, the hepatocyte growth factor receptor is amplified in 8% of gastroesophageal (GO) malignancies and associated with poor prognosis. Therapeutic targeting of MET amplification and MET mutations has the potential to improve outcomes for patients with GO cancers (GOC).

AREAS COVERED

The efficacy of MET inhibition (METi) in preclinical studies has yet to translate into meaningful improvements in the treatment paradigm for unselected GOC. MET amplification has been proposed as a superior modality for patient selection; however even if confirmed, frequency and duration of response to METi are limited by rapid activation of primary and secondary resistance pathways. These observations illustrate the challenges inherent in the application of precision oncology predicated on the theory of oncogenic addiction.

EXPERT OPINION

A standardized definition of MET positivity is critical to enhance patient selection. Early successes targeting the METex14 skipping mutation demonstrate the potent therapeutic effects of METi in a clearly molecularly defined cohort. There is robust preclinical rationale and early-phase data supporting exploitation of immune system interaction with MET. Pragmatic investigation of rational therapeutic combinations based on molecular profiling of both primary and metastatic disease sites with sequential circulating tumor DNA analysis can inform successful clinical development of METi agents in GOC.

Laparoscopic versus Open Surgery for Gastric Cancer in Western Countries: A Systematic Review and Meta-Analysis of Short- and Long-Term Outcomes

Background. The advantages of a laparoscopic approach for the treatment of gastric cancer have already been demonstrated in Eastern Countries. This review and meta-analysis aims to merge all the western studies comparing laparoscopic (LG) versus open gastrectomies (OG) to provide pooled results and higher levels of evidence. Methods. A systematic literature search was performed in MEDLINE(PubMed), Embase, WebOfScience and Scopus for studies comparing laparoscopic versus open gastrectomy in western centers from 1980 to 2021. Results. After screening 355 articles, 34 articles with a total of 24,098 patients undergoing LG (5445) or OG (18,653) in western centers were included. Compared to open gastrectomy, laparoscopic gastrectomy has a significantly longer operation time (WMD = 47.46 min; 95% CI = 31.83−63.09; p < 0.001), lower blood loss (WMD = −129.32 mL; 95% CI = −188.11 to −70.53; p < 0.0001), lower analgesic requirement (WMD = −1.824 days; 95% CI = −2.314 to −1.334; p < 0.0001), faster time to first oral intake (WMD = −1.501 days; 95% CI = −2.571 to −0.431; p = 0.0060), shorter hospital stay (WMD = −2.335; 95% CI = −3.061 to −1.609; p < 0.0001), lower mortality (logOR = −0.261; 95% the −0.446 to −0.076; p = 0.0056) and a better 3-year overall survival (logHR 0.245; 95% CI = 0.016−0.474; p = 0.0360). A slight significant difference in favor of laparoscopic gastrectomy was noted for the incidence of postoperative complications (logOR = −0.202; 95% CI = −0.403 to −0.000 the = 0.0499). No statistical difference was noted based on the number of harvested lymph nodes, the rate of major postoperative complication and 5-year overall survival. Conclusions. In Western centers, laparoscopic gastrectomy has better short-term and equivalent long-term outcomes compared with the open approach, but more high-quality studies on long-term outcomes are required.

Adverse impact of postoperative intra-abdominal infectious complications on cancer recurrence-related survival after curative gastric cancer surgery

BACKGROUND

This study aimed to evaluate the impact of postoperative intra-abdominal infectious complications (PICs) on survival after surgery for gastric cancer.

METHODS

A total of 152 patients who underwent curative gastrectomy for gastric cancer were included. The effect of clinicopathological features and PICs on recurrence-free survival (RFS) and overall survival (OS) were investigated.

RESULTS

The median age was 67 years. The pathological stage was stage I (61), II (40), and III (51). Thirty-two patients (21.1%) had PICs: 9, pancreatic fistula; 14, anastomotic leakage; and 17, intra-abdominal abscess. The five-year RFS and OS rates were significantly lower in patients with PICs than in those without PICs (63.4 vs. 85.6%; p < 0.01 and 56.4 vs. 80.3%; p < 0.01, respectively). In multivariate analysis, intraoperative blood loss was an independent prognostic factor for PICs.

CONCLUSIONS

Patients with PICs had worse clinical outcomes. Reducing intraoperative bleeding may improve the prognosis of gastric cancer.

Comparison of 4 lymph node staging systems for the prognostic prediction of esophagogastric junction adenocarcinoma with ≤15 retrieved lymph nodes

BACKGROUND

Directly applying the 8th American Joint Committee on Cancer (AJCC) Tumor Node Metastasis (TNM) staging system to evaluate the prognosis of patients with esophagogastric junction adenocarcinoma (AEG) might lead to under-staging, when insufficient lymph nodes were retrieved during surgery. The prognostic value of 4 lymph nodes staging systems, 8th AJCC TNM N stage, lymph node ratio (LNR), log odds of positive lymph nodes (LODDS), and negative lymph nodes (NLN), in AEG patients having ≤15 retrieved lymph nodes were compared.

METHODS

869 AEG patients diagnosed between 2004 and 2012 with ≤15 retrieved lymph nodes were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Univariate and multivariate Cox regression analyses were conducted to assess the association of cancer-specific survival (CSS) and overall survival (OS) with 8th AJCC TNM N stage, LNR, LODDS, and NLN respectively. Predictive survival ability was assessed and compared using linear trend χ2 score, likelihood ratio (LR) test, Akaike information criterion (AIC), Harrell concordance index (C-index), and Receiver Operative Curve (ROC).

RESULTS

The N stage, LNR, LODDS, and NLN were all independent prognostic predictors for CSS and OS in multivariate Cox models. Comparatively, LODDS demonstrated higher linear trend χ2 score, LR test score, C-index and integrated area under the curve (iAUC) value, and lower AIC in CSS compared to the other three systems. Moreover, for patients without regional lymph node metastasis, NLN showed higher C-index and lower AIC.

CONCLUSIONS

LODDS showed better predictive performance than N, LNR, and NLN among patients with node-positive patients while NLN performed better in node-negative patients. A combination of LODDS and NLN has the potential to provide more prognostic information than the current AJCC TNM classification.

A comparative study on perioperative outcomes between robotic versus laparoscopic D2 total gastrectomy

OBJECTIVE

Robotic surgery has been increasingly used worldwide owing to its advanced features. However, the significant benefits of robotic total gastrectomy (RTG) over laparoscopic total gastrectomy (LTG) have yet to be demonstrated. We conducted a prospective cohort study to compare the safety and efficacy of robotic and laparoscopic total gastrectomy (LTG) with D2 lymphadenectomy for AGC.

METHODS

Between March 26, 2018 and July 30, 2021, 155 patients between 18 and 80 years of age with locally advanced gastric cancer (cT2-4a, N0/+, M0) were enrolled. The perioperative outcomes within 30 days after surgery were compared between the RTG (n = 69) and LTG (n = 73) groups on a per-protocol (PP) basis. Postoperative complications were evaluated according to the Clavien-Dindo classification.

RESULTS

The overall postoperative morbidity rate was 21.74% in the RTG group and 28.77% in the LTG group with no significant difference (P = 0.44), RTG was associated with a lower incidence of pneumonia (4.35% vs. 15.07%, P = 0.047). No mortality was observed in either group. There was no significant difference in the total operative time (284.48 vs. 271.73 min, P = 0.171), but RTG was associated with a lower estimated volume of blood loss (110 vs. 150 ml, P < 0.001) and more total retrieved lymph nodes (LNs) (41.36 vs 35.1, P = 0.019), more extraperigastric LNs (14.91 vs. 12.19, P = 0.024) and more LNs in the suprapancreatic areas (14.68 vs. 11.82, P = 0.017). The laboratory data (amylase, inflammatory, Albumin and T lymphocyte levels) of the RTG group were better than those of the LTG group.

CONCLUSION

According to the results of this prospective cohort study, for patients with locally advanced gastric cancer, Robotic surgery has advantages over laparoscopic surgery for radical total gastrectomy with D2 lymphadenectomy performed by well-trained doctors.

Evolution of treatment in gastric cancer- a systematic review

Multimodality is the standard of care in gastric cancer but surgery remains the mainstay of curative treatment. As we are heading towards a more conservative approach for functional preservation without compromising oncological outcomes in all malignancies, the guidelines keeps changing based on various studies.The extent of surgery used to vary between the east and west, with the east performing more radical surgery and the west more reliant on multimodality therapy. This practice has been changing in the recent times.In this article we have reviewed how the treatment protocols of gastric cancer has evolved and modified, highlighting the practice changing trials.

Clinical Application of Indocyanine Green Fluorescence Technology in Laparoscopic Radical Gastrectomy

Background

This study aimed to observe the application and evaluate the feasibility and safety of indocyanine green (ICG) fluorescence technology in laparoscopic radical gastrectomy (LRG).

Methods

Patients who underwent LRG & D2 lymphadenectomy at Qilu Hospital of Shandong University were included between January 2018 and August 2019. According to whether endoscopic injection of ICG was performed, patients were assigned to the ICG group (n=107) and the control group (n=88). The clinicopathologic features, retrieved lymph nodes, postoperative recovery, and follow-up data were compared between the two groups.

Results

Baseline characteristics are comparable. The ICG group had a significantly larger number of lymph nodes retrieved (49.55 ± 12.72 vs. 44.44 ± 10.20, P<0.05), shorter total operation time (min) (198.22 ± 13.14 vs. 202.50 ± 9.91, P<0.05), shorter dissection time (min) (90.90 ± 5.34 vs. 93.74 ± 5.35, P<0.05) and less blood loss (ml) (27.51 ± 12.83 vs. 32.02 ± 17.99, P<0.05). The median follow-up time was 29.0 months (range 1.5-43.8 months), and there was no significant difference between the ICG group and the control group in 2-year OS (87.8% vs. 82.9%, P>0.05) or DFS (86.0% vs. 80.7%, P>0.05).

Conclusions

ICG fluorescence technology in laparoscopic radical gastrectomy has advantages in LN dissection, operation time, and intraoperative blood loss. The 2-year OS and 2-year DFS rates between the two groups were comparable. In conclusion, ICG fluorescence technology is feasible and safe.

Assessment of indocyanine green fluorescence lymphography on lymphadenectomy during minimally invasive gastric cancer surgery: a systematic review and meta-analysis

BACKGROUND

In recent years, indocyanine green fluorescence lymphography has been introduced for lymphatic mapping in gastric cancer surgery. The aim of this study was to investigate the efficacy of ICGFL in lymph node dissection during minimally invasive surgery for gastric cancer.

METHODS

A systematic review of electronic databases including PubMed, Embase, Web of Science, the Cochrane Library, and China National Knowledge Infrastructure was performed from the inception to January 2021 for all studies comparing ICGFL with non-ICGFL in GC patients undergoing minimal access gastrectomy. The primary outcome was the total number of harvested lymph nodes. The secondary endpoints were the number of metastatic LNs, operative time, estimated blood loss, and postoperative complications. The registration number of this protocol is PROSPERO CRD42020203443.

RESULTS

A total of 13 studies including 1882 participants were included. In this meta-analysis, the use of ICGFL was associated with a higher number of harvested LNs (40.33 vs. 33.40; MD = 6.93; 95%CI: 4.28 to 9.58; P < 0.0001; I2 = 86%). No significant difference was found between the ICGFL and control groups in terms of metastatic LNs (2.63 vs. 2.42; MD = 0.21; 95%CI: -0.46 to 0.87; P = 0.54; I2 = 0%). In addition, the use of ICGFL could be safely performed without increasing the operative time (P = 0.49), estimated blood loss (P = 0.26) and postoperative complications (P = 0.54).

CONCLUSION

The use of ICGFL may be a useful tool facilitating complete lymph node dissection during minimally invasive GC resection. However, more high-quality RCTs with large sample size are needed to validate this issue.

Impact of the Deep Neuromuscular Block on Oncologic Quality of Laparoscopic Surgery in Obese Gastric Cancer Patients: A Randomized Clinical Trial

BACKGROUND

Obesity can hinder laparoscopic procedures and impede oncological safety during laparoscopic cancer surgery. Deep neuromuscular block (NMB) reportedly improves laparoscopic surgical conditions, but its oncological benefits are unclear. We aimed to evaluate whether deep NMB improves the oncologic quality of laparoscopic cancer surgery in obese patients.

STUDY DESIGN

We conducted a double-blinded, parallel-group, randomized, phase 3 trial at 9 institutions in Korea. Clinical stage I and II gastric cancer patients with a BMI at or above 25 kg m -2 were eligible and randomized 1:1 ratio to the deep or moderate NMB groups, with continuous infusion of rocuronium (0.5-1.0 and 0.1-0.5 mg kg -1 h -1, respectively). The primary endpoint was the number of retrieved lymph nodes (LNs). The secondary endpoints included the surgeon's surgical rating score (SRS) and interrupted events.

RESULTS

Between August 2017 and July 2020, 196 patients were enrolled. Fifteen patients were excluded, and 181 patients were finally included in the study. There was no significant difference in the number of retrieved LNs between the deep (N = 88) and moderate NMB groups (N = 93; 44.6 ± 17.5 vs 41.5 ± 16.9, p = 0.239). However, deep NMB enabled retrieving more LNs in patients with a BMI at or above 28 kg/m2 than moderate NMB (49.2 ± 18.6 vs 39.2 ± 13.3, p = 0.026). Interrupted events during surgery were lower in the deep NMB group than in the moderate NMB group (21.6% vs 36.6%; p = 0.034). The SRS was not influenced by NMB depth.

CONCLUSION

Deep NMB provides potential oncologic benefits by retrieving more LNs in patients with BMI at or above 28 kg/m2 during laparoscopic gastrectomy.

Postoperative mortality and morbidity after D2 lymphadenectomy for gastric cancer: A retrospective cohort study

BACKGROUND

Surgery for gastric cancer is a complex procedure and lymphadenectomy is often mandatory. Postoperative mortality and morbidity after curative gastric cancer surgery is not insignificant.

AIM

To evaluate the factors determining mortality and morbidity in a population of patients undergoing R0 resection and D2 lymphadenectomy for gastric cancer.

METHODS

A retrospective analysis of clinical data and pathological characteristics (age, sex, primary site of the tumor, Lauren histotype, number of positive lymph nodes resected, number of negative lymph nodes resected, and depth of invasion as defined by the standard nomenclature) was conducted in patients with gastric cancer. For each patient we calculated the Kattan's score. We arbitrarily divided the study population of patients into two groups based on the nomogram score (< 100 points or ≥ 100 points). Prespecified subgroups in these analyses were defined according to age (≤ 65 years or > 65 years), and number of lymph nodes retrieved (≤ 35 lymph nodes or > 35 lymph nodes). Uni- and multivariate analysis of clinical and pathological findings were performed to identify the factors affecting postoperative mortality and morbidity.

RESULTS

One-hundred and eighty-six patients underwent a curative R0 resection with D2 lymphadenectomy. Perioperative mortality rate was 3.8% (7 patients); a higher mortality rate was observed in patients aged > 65 years (P = 0.002) and in N+ patients (P = 0.04). Following univariate analysis, mortality was related to a Kattan's score ≥ 100 points (P = 0.04) and the presence of advanced gastric cancer (P = 0.03). Morbidity rate was 21.0% (40 patients). Surgical complications were observed in 17 patients (9.1%). A higher incidence of morbidity was observed in patients where more than 35 lymph nodes were harvested (P = 0.0005).

CONCLUSION

Mortality and morbidity rate are higher in N+ and advanced gastric cancer patients. The removal of more than 35 lymph nodes does not lead to an increase in mortality.

D2 Lymphadenectomy as an Independent Prognostic Factor in Gastric Cancer

Background: The last decades have been marked by debates based on the importance of lymphadenectomy in gastric cancer, lymphadenectomy being a topic of controversy between the Western Surgical Societies and the Asian side. Lymphadenectomy is currently a globally accepted standard in the treatment of gastric cancer.

Methods: The present study was performed prospectively on a number of 93 patients diagnosed with gastric cancer, who underwent radical gastrectomy with lymphadenectomy in the Surgery Department of the Emergency County Clinical Hospital, Constanta, between January 2012 - December 2016. In 70 cases, an extended D2 or standard D2 lymphadenectomy was performed, and for 23 patients: D1 + lymphadenectomy. The data were statistically analyzed in order to determine the prognostic value of lymphadenectomy in gastric cancer.

Results: The average age was 65.88 ± 8.80 years. The mean number of lymph nodes harvested in D2 lymphadenectomy was 22.8 ± 7.60, with limits between 15 and 43, and the number of positive lymph nodes ranged from a minimum of 0 to a maximum of 37. Histopathological exam of specimens showed that only 17.2% of patients with gastric cancers were without lymph node metastases (pN0), while 45.16% were in the pN3 stage. Analysis of survival curves revealed that 5-year survival was significantly higher in D2 lymphadenectomy compared to D1 + lymphadenectomy (23.8% vs. 8.7%).

Conclusions: The current study validates D2 lymphadenectomy as a standard technique and the superiority of the prognosis in gastric cancer patients through results obtained in terms of 5-year survival.

Significance of Lymph Node Metastasis in the Treatment of Gastric Cancer and Current Challenges in Determining the Extent of Metastasis

The stomach exhibits abundant lymphatic flow, and metastasis to lymph nodes is common. In the case of gastric cancer, there is a regularity to the spread of lymph node metastasis, and it does not easily metastasize outside the regional nodes. Furthermore, when its extent is limited, nodal metastasis of gastric cancer can be cured by appropriate lymph node dissection. Therefore, identifying and determining the extent of lymph node metastasis is important for ensuring accurate diagnosis and appropriate surgical treatment in patients with gastric cancer. However, precise detection of lymph node metastasis remains difficult. Most nodal metastases in gastric cancer are microscopic metastases, which often occur in small-sized lymph nodes, and are thus difficult to diagnose both preoperatively and intraoperatively. Preoperative nodal diagnoses are mainly made using computed tomography, although the specificity of this method is low because it is mainly based on the size of the lymph node. Furthermore, peripheral nodal metastases cannot be palpated intraoperatively, nodal harvesting of resected specimens remains difficult, and the number of lymph nodes detected vary greatly depending on the skill of the technician. Based on these findings, gastrectomy with prophylactic lymph node dissection is considered the standard surgical procedure for gastric cancer. In contrast, several groups have examined the value of sentinel node biopsy for accurately evaluating nodal metastasis in patients with early gastric cancer, reporting high sensitivity and accuracy. Sentinel node biopsy is also important for individualizing and optimizing the extent of uniform prophylactic lymph node dissection and determining whether patients are indicated for function-preserving curative gastrectomy, which is superior in preventing post-gastrectomy symptoms and maintaining dietary habits. Notably, advancements in surgical treatment for early gastric cancer are expected to result in individualized surgical strategies with sentinel node biopsy. Chemotherapy for advanced gastric cancer has also progressed, and conversion gastrectomy can now be performed after downstaging, even in cases previously regarded as inoperable. In this review, we discuss the importance of determining lymph node metastasis in the treatment of gastric cancer, the associated difficulties, and the need to investigate strategies that can improve the diagnosis of lymph node metastasis.

Pancreas-contactless gastrectomy for gastric cancer prevents postoperative inflammation

BACKGROUND

Pancreas-related complications after laparoscopic gastrectomy (LG) for gastric cancer can be fatal. We developed a gastrectomy procedure with no pancreas contact to prevent such complications and herein report the surgical outcomes.

METHODS

We retrospectively reviewed 182 consecutive patients with gastric cancer who underwent LG at Kitasato University Hospital from January 2017 to January 2020. These patients were divided into a pancreas-contact group (C group) and pancreas-contactless group (CL group) for comparison of postoperative complications, and inflammatory parameters such as body temperature (BT) and C-reactive protein (CRP).

RESULTS

Postoperative complications of CDc grade ≧ IIIa were significantly fewer in the CL group than in the C group [0/76 (0%) vs. 6/106 (5.7%), P = 0.035]. The median drain amylase (drain-AMY) on postoperative day 1 (POD1) was significantly lower in the CL group than in the C group (641 vs. 1162 IU/L, P = 0.02), as was BT at POD1 (37.4 °C vs. 37.7 °C, P = 0.04), the patient group with a BT above 37.5 °C at POD3 [5/76 (6.5%) vs. 18/106 (17%), P = 0.037], and those showing a CRP above 20.0 mg/dL at POD3 [5/76 (6.5%) vs. 20/106 (19%), P = 0.018].

CONCLUSIONS

Our technique to prevent pancreas contact during supra-pancreatic lymph node dissection during LG could minimize the inflammatory response and prevent further postoperative complications. Further large-scale, prospective studies are now required.

Pathological N3 Stage (pN3/ypN3) Gastric Cancer: Outcomes, Prognostic Factors and Pattern of Recurrences After Curative Treatment

BACKGROUND

pN3 or ypN3 stage gastric cancers (GCs) are known to have aggressive clinical behaviour. This study aimed to investigate factors affecting survival and pattern of recurrences of N3 stage GCs, treated with curative intent.

METHODS

A total of 196 GC patients, operated on at the Tata Memorial Centre from 2003 to 2017 and reported as pN3 or ypN3 status on histopathology after D2 gastrectomy were included in this retrospective analysis.

RESULTS

On multivariate analysis, use of NACT (neoadjuvant chemotherapy) and LN ratio (≤ 0.5/> 0.5) emerged as significant predictors for long-term survival. Patients who received NACT but were still harbouring N3 nodes (ypN3; n = 102) had a worse prognosis than those operated on upfront (pN3; n = 94), with a median survival of 19 months versus 24 months respectively (p = 0.003). The 5-year overall survival of the entire cohort was 16.3% (95% CI 12.8-19.8%), while 5-year disease-free survival (DFS) was 14.6% (95% CI 12.6-20%). Adjuvant chemoradiotherapy, though offered in a small number of patients (n = 38) resulted in improvement in DFS. Median DFS of adjuvant CT versus adjuvant CRT was 13 months versus 23 months (p = 0.020). The commonest site of relapse was the peritoneum (49.18%) and incidence of isolated loco-regional failure was 10.7%.

CONCLUSION

In GCs with N3 stage determined after radical D2 gastrectomy, LN ratio of > 0.5 and ypN3 status are predictors of poor prognosis. Considering the high incidence of peritoneal and loco-regional relapse in these patients, the role of more radical surgery, adjuvant chemoradiotherapy after upfront resection and intraperitoneal chemotherapy should be evaluated in prospective randomized clinical trials.