Chemotherapy vs chemoradiotherapy after surgery and preoperative chemotherapy for resectable gastric cancer (CRITICS): an international, open-label, randomised phase 3 trial. Lancet Oncol. 2018;19:616-628. [PMID: 29650363 DOI: 10.1016/s1470-2045(18)30132-3]

The efficacy and safety of PD-1/PD-L1 inhibitors plus chemotherapy versus chemotherapy alone in advanced or metastatic gastric or gastroesophageal junction cancer: a meta-analysis of randomized controlled trials

BACKGROUND

The combination chemotherapy of alpha-PD-1/PD-L1 has become the standard treatment option for some cancer patients. However, studies have shown that not all patients benefit from improved survival rates, especially the use of PD-1/PD-L1 inhibitors in combination with chemotherapy for progression-free survival (PFS) in patients with gastric or gastroesophageal cancer (GC/GEJC) remains highly controversial. To address this issue, we conducted a meta-analysis of randomized controlled trials (RCTs) aimed at comparing the efficacy of PD-1/PD-L1 inhibitors combined with chemotherapy versus chemotherapy in GC/GEJC patients.

METHOD

By searching relevant databases, RCTs published up to November 2024 were collected, and the hazard ratios (HR) and 95% confidence intervals (CI) of overall survival (OS) and PFS were calculated. Meanwhile, the odds ratios (OR) and 95% CI of treatment-related adverse events (TRAEs) were evaluated.

RESULT

A total of 6842 patients were included in seven trials. In the summary analysis of OS, compared with the chemotherapy group, the PD-1/PD-L1 inhibitor combined with the chemotherapy group showed significant improvement in OS (HR = 0.80; 95% CI = 0.76-0.85; p < 0.0001) and PFS (HR = 0.86; 95% CI = 0.71-0.81; p < 0.0001). Additionally, there were significant differences in the incidence of TRAEs (OR = 1.59; 95% CI = 1.21-2.02; p = 0.0001) and grade 3-4 TRAEs (OR = 1.43; 95% CI = 1.30-1.58; p < 0.0001).

CONCLUSION

When compared to chemotherapy, the combination of PD-1/PD-L1 inhibitors with chemotherapy improves survival but with higher toxicity risks, requiring careful benefit-risk evaluation in clinical practice.

Gastric Carcinoma Patients with Advanced Pathological Lymph Node Stage Benefit from Postoperative Radiotherapy: A Retrospective Analysis

BACKGROUND

The relationship between regional pathological lymph node status and the benefit of postoperative radiotherapy for gastric cancer remains controversial.

METHODS

This study included all surgically treated patients diagnosed with positive histology and more than 15 examined lymph nodes between January 2007 and December 2019, using data from the SEER database. Patients who received adjuvant chemotherapy were compared by propensity score matching (PSM), with overall survival (OS) as the primary endpoint and adjuvant radiotherapy (RT) as the only variable. Results of subgroup analyses are presented in a forest plot.

RESULTS

We firstly analyzed the number of patients receiving adjuvant RT and observed a gradual decline from 2000 to 2021. A total of 1882 patients were included from 2007 to 2019, with 1301 (69.1%) in the adjuvant RT group and 581 (30.9%) in the no-adjuvant RT group. After PSM, each group included 573 patients. Overall, adjuvant RT did not significantly improve 3-year OS (55.5% vs. 51.1%, p = 0.07). However, in subgroups of patients with pathologic lymph node metastasis (pN3-stage), aged 55-70 years, with tumor size > 89 mm and T3-stage, adjuvant RT was associated with improved outcome (p < 0.05). Further PSM and survival analysis based on different pathological lymph node stages suggested an association between adjuvant RT and outcomes. Improved survival outcomes were observed in pathologically lymph node positive (pN +) and pN3 groups, but no similar effects were seen in pN1 and pN2 groups. For pN0 patients, although no statistical significance was found, the data suggest that adjuvant RT may not provide additional benefit.

CONCLUSION

Adjuvant RT was associated with significantly better prognosis in pN3-stage patients. More researches are needed to further validate the role of adjuvant RT in gastric cancer.

Machine Learning for Predicting Postoperative Functional Disability and Mortality Among Older Patients With Cancer: Retrospective Cohort Study

Background

The global cancer burden is rapidly increasing, with 20 million new cases estimated in 2022. The world population aged ≥65 years is also increasing, projected to reach 15.9% by 2050, making cancer control for older patients urgent. Surgical resection is important for cancer treatment; however, predicting postoperative disability and mortality in older patients is crucial for surgical decision-making, considering the quality of life and care burden. Currently, no model directly predicts postoperative functional disability in this population.

Objective

We aimed to develop and validate machine-learning models to predict postoperative functional disability (≥5-point decrease in the Barthel Index) or in-hospital death in patients with cancer aged ≥ 65 years.

Methods

This retrospective cohort study included patients aged ≥65 years who underwent surgery for major cancers (lung, stomach, colorectal, liver, pancreatic, breast, or prostate cancer) between April 2016 and March 2023 in 70 Japanese hospitals across 6 regional groups. One group was randomly selected for external validation, while the remaining 5 groups were randomly divided into training (70%) and internal validation (30%) sets. Predictor variables were selected from 37 routinely available preoperative factors through electronic medical records (age, sex, income, comorbidities, laboratory values, and vital signs) using crude odds ratios (P<.1) and the least absolute shrinkage and selection operator method. We developed 6 machine-learning models, including category boosting (CatBoost), extreme gradient boosting (XGBoost), logistic regression, neural networks, random forest, and support vector machine. Model predictive performance was evaluated using the area under the receiver operating characteristic curve (AUC) with 95% CI. We used the Shapley additive explanations (SHAP) method to evaluate contribution to the predictive performance for each predictor variable.

Results

This study included 33,355 patients in the training, 14,294 in the internal validation, and 6711 in the external validation sets. In the training set, 1406/33,355 (4.2%) patients experienced worse discharge. A total of 24 predictor variables were selected for the final models. CatBoost and XGBoost achieved the largest AUCs among the 6 models: 0.81 (95% CI 0.80-0.82) and 0.81 (95% CI 0.80-0.82), respectively. In the top 15 influential factors based on the mean absolute SHAP value, both models shared the same 14 factors such as dementia, age ≥85 years, and gastrointestinal cancer. The CatBoost model showed the largest AUCs in both internal (0.77, 95% CI 0.75-0.79) and external validation (0.72, 95% CI 0.68-0.75).

Conclusions

The CatBoost model demonstrated good performance in predicting postoperative outcomes for older patients with cancer using routinely available preoperative factors. The robustness of these findings was supported by the identical top influential factors between the CatBoost and XGBoost models. This model could support surgical decision-making while considering postoperative quality of life and care burden, with potential for implementation through electronic health records.

Gastric cancer

Gastric cancer remains a major health challenge worldwide, with nearly 1 million new cases annually contributing to more than 650 000 deaths. Epidemiologically, gastric cancer shows substantial geographical variation in incidence, with higher rates in Asia, South America, and eastern Europe, and a rapid increase in early-onset cases among people younger than 50 years. Key risk factors for gastric cancer include Helicobacter pylori infection, diet, obesity, smoking, and genetic predisposition. Early detection through comprehensive diagnostic procedures is crucial for optimising treatment outcomes. Standard treatment approaches for locally advanced gastric cancer include surgical resection, particularly D2 lymphadenectomy, complemented by chemotherapy and radiotherapy. There is increasing implementation of minimally invasive surgical techniques for operable disease and integration of immune checkpoint inhibitors and targeted therapies for advanced stages. Emerging therapies, such as novel targeted treatments and next-generation immunotherapies, show promise in improving survival and quality of life. Future directions in the management of gastric cancer focus on precision medicine, continued advancement in immunotherapy, novel early detection methods, and a multidisciplinary approach to care. These strategies aim to enhance the overall effectiveness of treatment and prognosis worldwide.

Outcomes of Intraoperative Radiotherapy for Locally Advanced Adenocarcinoma of the Esophagogastric Junction After Neoadjuvant Therapy: A Single-Arm, Phase 1 Trial From the Chinese National Cancer Center

BACKGROUND

The role of intraoperative radiotherapy (IORT) for adenocarcinoma of the esophagogastric junction (AEG) remains uncertain. Therefore, a prospective phase 1 trial was conducted to assess the safety and feasibility of IORT for locally advanced AEG.

METHODS

The study enrolled patients with AEG at stages II-IVA from January 2019 to September 2019. Eligible patients received esophagectomy and a single fraction of electron beam radiotherapy. The primary endpoint of the study was a safety profile for IORT. Additionally, survival outcomes and the locoregional recurrence rate (LRR) were compared between the non-IORT and IORT cohorts using propensity score-matching.

RESULTS

For 15 (93.8 %) of the 16 patients in the study, R0 resection was successfully achieved, with only one patient undergoing R1 resection. A total postoperative complication morbidity rate of 43.8 % (7/16) was observed, with major complications (Clavien-Dindo classification ≥3) in 12.5 % of the cases (2/16). Total treatment-related adverse events were reported for seven patients (43.8 %, 7/16). After matching, a lower LRR was observed in the IORT group than in the non-IORT group (0 % [0/12] vs 33.3 % [4/12]; p = 0.028). However, the two groups did not differ significantly in 3-year progression-free survival (PFS: IORT [50.9 %] vs non-IORT [53.4 %]; p = 0.93) or 3-year overall survival (OS: IORT [58.3 %] vs IORT [72.9 %]; p = 0.23).

CONCLUSIONS

The current study demonstrated favorable feasibility and safety of IORT for locally advanced AEG. Although IORT is beneficial for improving local control, it may not prolong PFS or OS for patients with locally advanced AEG. A phase 2 trial is warranted for further validation of these outcomes.

Risk analysis of cardiovascular mortality after gastric cancer diagnosis: a large population-based study

Background

The increasing prevalence of cardiovascular mortality is becoming a significant worry for individuals who have survived cancer. The aim of this study is to investigate the dynamic trend of cardiovascular death in patients with gastric cancer (GC) and identify the risk factors associated with cardiovascular disease (CVD)-specific mortality in non-metastatic GC patients.

Methods

In the present study, 29,324 eligible patients diagnosed with primary GC were collected from the Surveillance, Epidemiology, and End Results (SEER) database. Standardized mortality ratios (SMRs) adjusted by age, gender, calendar year, and race were calculated. Fine-Gray's competing risk models were taken to identify the prognostic factors of cardiovascular death in GC patients.

Results

There were 1083 (5.2%) cardiovascular deaths among 20,857 patients with local/regional GC, and 76 (0.9%) cardiovascular deaths among 8,467 patients with metastatic GC. The SMRs of CVD-specific mortality continuously increased since the 1975s throughout the 2015s. The competing risk models showed that age (>75 years vs. 0-50 years, HR: 6.602, 95% CI: 4.356-10.006), T stage (T4 vs. T1, HR:0.524, 95% CI: 0.370-0.741), N stage (N3 vs. N0, HR: 0.557, 95% CI: 0.343-0.903), surgery (Yes vs. No, HR: 0.551, 95% CI: 0.461-0.659), and radiotherapy (Yes vs. No, HR: 1.011, 95% CI: 1.011-1.437) were predictive of CVD-specific mortality. Furthermore, based on the results of the competing risk analyses, a nomogram was constructed to predict the probability of CVD-specific mortality for local/regional GC patients.

Conclusion

Our study demonstrated the dynamic trend of cardiovascular death in GC patients, and identified prognostic risk predictors, highlighting the importance cardio-oncology teams in offering comprehensive care and long-term follow-up for GC patients.

Long-term trends in the clinical management and outcomes of patients with gastroesophageal cancer in Norway

BACKGROUND AND PURPOSE

Gastroesophageal cancers are highly prevalent internationally, with many patients diagnosed with metastatic disease, leading to challenging treatment and poor survival. This study uses real-world evidence from a population-level database to describe demographics, clinical characteristics, initial treatment patterns, and survival for patients with gastroesophageal cancer in Norway.

MATERIAL AND METHODS

Individual patient data was sourced from the Cancer Registry of Norway for patients diagnosed with oesophageal squamous cell carcinoma (ESCC), oesophageal adenocarcinoma (EAC), gastroesophageal junction cancer (GEJC), and gastric cancer from 2001 to 2021, with follow-up from diagnosis to death or last follow-up. Treatment patterns were captured from 2010 to 2022, defined as curative or palliative based on surgery, chemotherapy, and radiotherapy.

RESULTS AND INTERPRETATION

The cohort included 14,334 Norwegian patients with gastroesophageal cancer; predominantly male, mean age 69-73 years, with a median follow-up of 9-11 months across cancer subtypes. Approximately 40% of patients received curative treatment, and multi-modality treatments increased for EAC, GEJC, and ESCC. Median survival ranged from 6 to 11 months for patients treated palliatively, and 17-95 months for those treated with curative intent. Interestingly, median survival was higher for patients with EAC and GEJC treated with neoadjuvant chemotherapy (86.1 and 75.1 months) versus neoadjuvant chemoradiotherapy (49.1 and 42.1 months), which was confirmed by a multivariate Cox regression model adjusted for age, sex, and disease stage. This study demonstrates that multimodal treatment strategies, consisting of chemotherapy and surgery, may be associated with improved survival outcomes for gastroesophageal cancers. Future studies are required to identify optimum treatment strategies for gastroesophageal cancer subtypes.

The current landscape of gastric cancer and gastroesophageal junction cancer diagnosis and treatment in China: a comprehensive nationwide cohort analysis

BACKGROUND

Gastric cancer is the fifth most common cancer globally and is associated with significant morbidity and mortality. Despite its alarming prevalence, limited comparative evidence exists on its treatment efficacy and prognosis across diverse China populations.

METHODS

To address this, our study used a large-scale dataset from the National Cancer Information Database, including data from 220,304 patients from 53 leading hospitals across 27 provinces in China.

RESULTS

From 2017 to 2023, early-stage (Stages I-II) gastric cancer diagnoses increased to 35.63% of all cancer cases. Our study evaluated the neoadjuvant treatment strategies, adjuvant post-operative therapy, first- and second-line management for progressive stages, alongside current gastric cancer treatment guidelines in China. Notably, immunotherapy accounted for 16.17% and 23.28% of first- and second-line treatments for late-stage gastric cancers, and 14.56% and 5.00% for neoadjuvant and adjuvant therapies, respectively. Analysis of survival rates revealed that the 1-, 2-, 3-, 4-, and 5-year survival rates were 74.07%, 54.89%, 44.21%, 37.97%, and 33.53%, respectively. The 5-year survival rates across stages I-IV were 85.07%, 49.34%, 35.56%, and 13.15%, respectively.

CONCLUSIONS

These findings offer critical insights into the current state of gastric cancer treatment in China and can inform future initiatives to improve therapeutic outcomes for patients with gastric cancer.

Evolution of Therapeutics for Locally Advanced Upper Gastrointestinal Adenocarcinoma

Upper gastrointestinal (GI) malignancies, including esophageal, gastroesophageal junction (GEJ), and gastric adenocarcinomas, remain a major global health concern, with poor overall survival and high recurrence rate despite aggressive treatment. Patients with very early tumors (cT1a) can benefit from endoscopic therapy. However, patients with locally advanced disease require multimodal therapies that may combine surgery, radiation, and systemic therapies. This review provides a comprehensive overview of recent advancements in the treatment of locally advanced upper GI adenocarcinomas. Surgical resection remains the cornerstone of curative treatment, with perioperative chemotherapy emerging as the standard of care. While preoperative chemoradiation has demonstrated some benefits in esophageal and GEJ cancers, recent data suggest a more limited role for radiation going forward. Immunotherapy has shown some promise in both the adjuvant and perioperative settings but has yet to establish definitive survival benefit. The integration of HER2-targeted therapies into treatment regimens for HER2-positive locally advanced gastroesophageal cancers has not yielded significant improvements, underscoring the need for more effective strategies. Ongoing research focuses on better predictive biomarkers, personalized treatment approaches, and potential organ preservation strategies for patients achieving a clinical complete response. Continued advancements in treatment modalities and precision medicine are critical to improving survival for patients with locally advanced upper GI adenocarcinomas.

Long-Term Prognostic Analysis of Chemoradiation Therapy Versus Chemotherapy after D2 Resection for High-Risk Gastric Cancer: Results From a Prospective Randomized Control Study

PURPOSE

To explore the population of patients who could benefit from adjuvant radiation therapy (RT) and investigated the value of postoperative chemoradiation therapy (CRT) in patients with gastric cancer after D2 resection.

METHODS AND MATERIALS

This randomized clinical trial enrolled patients between October 1, 2011, and December 31, 2019. Patients with gastric cancer who underwent D2 gastrectomy were randomized (1:1) to receive postoperative CRT or adjuvant chemotherapy after surgery. The adjuvant chemotherapy group received 8 cycles of SOX (S-1 + oxaliplatin) chemotherapy. RT was given after 4 to 6 cycles of SOX chemotherapy. RT comprised 45 Gy in 25 fractions of 1.8 Gy over 5 weeks by intensity modulated RT concurrently with S-1 chemotherapy. The primary endpoint was 3-year disease-free survival (DFS).

RESULTS

A total of 312 patients (median [IQR] age, 58 [50-64] years) were enrolled, including 157 patients randomized to the adjuvant chemotherapy group and 155 patients randomized to the adjuvant CRT group. The 3-year DFS was 66.7% for the control arm and 70.7% for the experimental arm (hazard ratio [HR], 0.82; 95% CI, 0.54-1.25; P = .35). We defined patients with pN stage ≥ N2 and extraperigastric lymph node metastasis as the high-risk group and the remaining patients as the low-risk group. The 3-year DFS rates for the high-risk group and the low-risk group were 59.3% and 76.8%, respectively (HR, 2.11; 95% CI, 1.39-3.22; P < .01). For high-risk patients, the 3-year DFS rates in the adjuvant chemotherapy and adjuvant CRT groups were 53.0% and 71.0%, respectively (HR, 0.53; 95% CI, 0.29-0.97; P < .05). More grade 3 and 4 acute toxic effects were observed in the adjuvant chemotherapy group than in the CRT group (41 patients [26.1%] vs 28 patients [18.5%]; P = .11), but the difference was not significant.

CONCLUSIONS

Subgroup analysis of this randomized clinical trial revealed that high-risk patients can benefit from adjuvant CRT.

Age-Related Differences in Gastric Adenocarcinoma from 2000-2020: A SEER Database Analysis

INTRODUCTION

Gastric cancer (GC) is the 5th most common malignancy worldwide. Adenocarcinoma accounts for 95% of all GC. While most cases of gastric adenocarcinoma (GAC) arise in older age males, a significant proportion of biological disparity exists between different ages. In this study, we aim to compare the demographics and prognostic outcomes of different ages of patients with GAC.

METHODS

This retrospective study utilized the GAC cases abstracted from the Surveillance, Epidemiology, and End Results Program's 17 registries dataset from 2000 to 2020. Cases were divided into different age group brackets to comparatively explore characteristics of GAC.

RESULTS

A total of 103,674 cases were identified. The median age was 69 years, with a significant proportion 39.7% (n = 41,154) falling within the 66-80 age bracket cases. Female proportions were higher in the ≤ 35 years age group 47.2% (n = 960) and ≥ 81 years age group 45.7% (n = 9,695). About 45.1% (n = 916) of ≤ 35 years age group cases were Hispanic, while 60% (n = 12,715) of ≥ 81 years age group cases were non-Hispanic White. Ages between 51-65 and 66-80 years had higher proportions of liver metastasis 17% and 16% than their younger and older peers. Age ≤ 35 years cases are more likely to present at cardia 20.5%. Male gender had the worst survival across all age groups, with the worst in the ≤ 35 age group hazard ratio (H.R) 1.22(1.007 - 1.250 p < 0.001). Black had the worst survival across all ages, with the worst in the ≤ 35 years age group H.R 1.405 (1.164 - 1.696 p < 0.001). When plotted against other races in each age group, Hispanics had poor survival at young ages H.R 1.224 (1.069 - 1.401) and superior survival at older ages, with H.R 0.944 (0.902 - 0.987) in the ≥ 81 age group. Tumors located in the greater curvature and overlapping lesions demonstrated worse prognosis compared to cardia. Conversely, tumors in the pylorus and lesser curvature generally exhibited better prognosis.

CONCLUSION

In the United States GAC predominantly affects older adults, but early-onset cases exhibit aggressive histologies and poor survival, particularly more common in Hispanics. Black individuals face the worst survival outcomes across all age groups. Gender inclination towards males shrinks at the extremes of ages. At different age brackets, the demographics and prognosis changes, necessitating customized interventions.

Hounsfield units predict vertebral compression fractures in gastric cancer survivors after adjuvant irradiation

PURPOSE

This study aimed to investigate the risk factors and predictive value of vertebral Hounsfield units (HUs) for vertebral compression fracture (VCF) development in gastric cancer (GC) patients who received adjuvant radiotherapy (RT).

MATERIALS AND METHODS

We retrospectively analyzed the data of 271 patients with non-metastatic GC who received adjuvant RT between 2010 and 2020. The vertebral bodies from 9th thoracic (T9) to 2nd lumbar (L2) were contoured in computed tomographies used for RT planning, and V30, V35, V40, mean doses, and HUs of vertebrae were documented. We conducted univariate and multivariate analyses to identify the risk factors for VCF development.

RESULTS

The median follow-up time was 35.7 months. VCF developed in 23 patients (8.5%) in a median of 30.6 months (range, 3.4 to 117.3) after the end of RT. In total, 37 vertebrae were fractured, with 14 located in T12, nine in L1, seven in T11, four in L2, and three in T10. Older age, female sex, non-smoking status, and lower median vertebrae HUs were significantly associated with VCF in the univariate analysis. In the multivariate analysis, lower median HUs of T12 vertebrae (odds ratio, 0.965; 95% confidence interval, 0.942 to 0.989; p = 0.004) remained significant. The optimal cut-off value for T12 HU was 205.1, with an area under the receiver operating characteristic curve of 0.765, sensitivity of 85.7%, and specificity of 65%.

CONCLUSION

The lower median HU value of T12 vertebrae is a significant and independent risk factor for VCF development in GC patients who received adjuvant RT. HUs values serve as a simple and reliable predictor of VCF development in this population.

Association between adjuvant radiotherapy in adults with gastric cancer and risk of second primary malignancy: a retrospective cohort study using the Surveillance, Epidemiology and End Results database

OBJECTIVES

This study aims to assess the association between adjuvant radiotherapy and the development of second primary malignancies (SPMs) and identify its determinants in patients who have undergone surgical treatment for gastric cancer.

DESIGN

Retrospective cohort study using the Surveillance, Epidemiology and End Results (SEER) database.

SETTING

Cohorts (18 registries, 2000-2018, from SEER) were screened for any malignancy that developed after sufficient latency from diagnosis of surgically treated non-metastatic gastric cancer.

PARTICIPANTS

24 777 surgically treated gastric cancer cases were included in the cohort. Among them, 6128 patients underwent adjuvant radiotherapy.

OUTCOME MEASURES

The cumulative incidence of SPMs was estimated using Fine and Gray's competing risk model and the radiotherapy-correlated risks were calculated using Poisson regression analysis.

RESULTS

Among patients with sufficient latency, there was no significant association between radiotherapy and the risk of developing second primary solid malignancies (relative risk=1.05, 95% CI 0.83 to 1.33) or haematological malignancies (relative risk=1.17, 95% CI 0.62 to 2.11). Interestingly, radiotherapy was associated with a reduced cumulative incidence of second lung and bronchus cancer compared with no radiotherapy, with a 15-year incidence of 1.4%-3.17% (p<0.05). Radiotherapy was not associated with a significant increase in standardised incidence ratios of SPMs.

CONCLUSIONS

Adjuvant radiotherapy was not associated with an increased risk of developing SPMs in surgically treated patients with gastric cancer. Clinical trials are warranted to further verify the findings.

Multimodality Treatment for Locally Advanced Gastric Adenocarcinoma

Gastric cancer is prevalent worldwide and is a leading cause of cancer-related death. Patients with GC often present at advanced stages at diagnosis. Patients with locally advanced diseases experience poor survival rates with surgery alone. Multimodality therapy, including peri-operative therapy and adjuvant therapy, has improved outcomes. However, there is no consensus on the optimal treatment approach. Molecular characteristics of GC may help guide treatment choices and studies are currently underway to evaluate other treatment modalities including immunotherapy and targeted therapy.

Histopathological response to chemotherapy and survival of mucinous type gastric cancer

BACKGROUND

Data on the clinicopathological characteristics of mucinous gastric cancer (muc-GC) are limited. This study compares the clinical outcome and response to chemotherapy between patients with resectable muc-GC, intestinal (int-GC), and diffuse (dif-GC) gastric cancer.

METHODS

Patients from the D1/D2 study or the CRITICS trial were included in exploratory surgery-alone (SAtest) or chemotherapy test (CTtest) cohorts. Real-world data from the Netherlands Cancer Registry on patients treated between with surgery alone (SAvalidation) and receiving preoperative chemotherapy with or without postoperative treatment (CTvalidation) were used for validation. Histopathological subtypes were extracted from pathology reports filed in the Dutch Pathology Registry and correlated with tumor regression grade (TRG) and relative survival (RS).

RESULTS

In the SAtest (n = 549) and SAvalidation (n = 8062) cohorts, muc-GC patients had a 5-year RS of 39% and 31%, similar to or slightly better than dif-GC (43% and 29%, P = .52 and P = .011), but worse than int-GC (55% and 42%, P = .11 and P < .001). In the CTtest (n = 651) and CTvalidation (n = 2889) cohorts, muc-GC showed favorable TRG (38% and 44% (near-) complete response) compared with int-GC (26% and 35%) and dif-GC (10% and 28%, P < .001 and P = .005). The 5-year RS in the CTtest and CTvalidation cohorts for muc-GC (53% and 48%) and int-GC (58% and 59%) was significantly better compared with dif-GC (35% and 38%, P = .004 and P < .001).

CONCLUSION

Recognizing and incorporating muc-GC into treatment decision-making of resectable GC can lead to more personalized and effective approaches, given its favorable response to preoperative chemotherapy in relation to int-GC and dif-GC and its favorable prognostic outcomes in relation to dif-GC.

Development of a Prognostic Nomogram for Overall Survival in Gastric Cancer Patients Who Underwent Adjuvant Chemoradiotherapy

PURPOSE

The aim of this study was to identify prognostic factors influencing overall survival (OS) in patients with gastric cancer treated with adjuvant chemoradiotherapy (CRT) and to develop a predictive model.

METHODS

We retrospectively evaluated 245 non-metastatic gastric cancer patients who received adjuvant CRT or radiotherapy from 2010 to 2020. Survival analyses were performed using the Kaplan-Meier method. Prognostic factors were identified through univariate and multivariate Cox regression analyses. A nomogram was constructed based on significant predictive factors for OS, including lymph node ratio, T classification, tumor location, and local recurrence.

RESULTS

The median follow-up duration was 41.5 months (range, 6-144.8 months). The 2- and 5-year OS and progression-free survival were 77% and 53% and 64% and 49%, respectively. In multivariate analysis, tumor location (distal vs. proximal), pT classification (pT1-2 vs. pT3-4), lymph node ratio (< 0.18 vs. ≥ 0.18), and presence of local recurrence were independent prognostic factors for OS. The optimal cut-off value for the total nomogram score predicting OS was 116 points. Patients with < 116 points had 2- and 5-year OS rates of 87% and 73%, respectively, compared to 67% and 30% for those with ≥ 116 points.

CONCLUSION

A nomogram was constructed incorporating lymph node ratio, T classification, tumor site, and local recurrence for gastric cancer patients receiving adjuvant CRT. Patients with a total score below 116 demonstrated higher survival rates. This nomogram may aid in defining optimal follow-up intervals.

A prognostic nomogram to predict the cancer-specific survival of patients with initially diagnosed metastatic gastric cancer: a validation study in a Chinese cohort

BACKGROUND

Few studies have been designed to predict the survival of Chinese patients initially diagnosed with metastatic gastric cancer (mGC). Therefore, the objective of this study was to construct and validate a new nomogram model to predict cancer-specific survival (CSS) in Chinese patients.

METHODS

We collected 328 patients with mGC from Northern Jiangsu People's Hospital as the training cohort and 60 patients from Xinyuan County People's Hospital as the external validation cohort. Multivariate Cox regression was used to identify risk factors, and a nomogram was created to predict CSS. The predictive performance of the nomogram was evaluated using the consistency index (C-index), the calibration curve, and the decision curve analysis (DCA) in the training cohort and the validation cohort.

RESULTS

Multivariate Cox regression identified differentiation grade (P < 0.001), T-stage (P < 0.05), N-stage (P < 0.001), surgery (P < 0.05), and chemotherapy (P < 0.001) as independent predictors of CSS. Nomogram of chemotherapy regimens and cycles was also designed by us for the prediction of mGC. Thus, these factors are integrated into the nomogram model: the C-index value was 0.72 (95% CI 0.70-0.85) for the nomogram model and 0.82 (95% CI 0.79-0.89) and 0.73 (95% CI 0.70-0.86) for the internal and external validation cohorts, respectively. Calibration curves and DCA also demonstrated adequate fit and ideal net benefit in prediction and clinical applications.

CONCLUSIONS

We established a practical nomogram to predict CSS in Chinese patients initially diagnosed with mGC. Nomograms can be used to individualize survival predictions and guide clinicians in making therapeutic decisions.

PDLIM1 Inhibits Chemoresistance by Blocking DNA Damage Repair in Gastric Cancer

OBJECTIVE

Current cisplatin (CDDP) resistance remains a major challenge in the treatment of advanced gastric cancer. To address the issue of drug resistance, we explored the regulatory functions of PDZ and LIM structural domain protein 1 (PDLIM1) in CDDP chemotherapy for gastric cancer.

METHODS

In this study, we analyzed PDLIM1 expression and prognosis using bioinformatics on publicly available data. PDLIM1 expression in a gastric mucosal epithelial cell line (GSE-1), CDDP- sensitive (SGC7901, BGC823) and CDDP-resistant gastric cancer cells was detected by RTqPCR and Western blotting. Cell proliferative capacity was assessed by knockdown of PDLIM1 and overexpression of PDLIM1 in cells administered in combination with cisplatin, and apoptotic levels were measured by CCK-8 and colony formation assay and by flow cytometry. Expression of breast cancer susceptibility gene 1 (BRCA1) and γH2AX was determined by Western blotting or immunofluorescence staining.

RESULTS

Downregulation of PDLIM1 was found in tumor tissues and cells, which was associated with poor clinical outcomes. Knockdown of PDLIM1 enhanced proliferation and attenuated apoptosis in gastric cancer cells. In addition, the therapeutic effects of CDDP on proliferation, apoptosis, and DNA damage repair were attenuated by PDLIM1 deletion.PDLIM1 expression was downregulated in CDDP-resistant tumor cells. Overexpression of PDLIM1 overcomes CDDP resistance in tumor cells as BRCA1 expression decreases and γH2AX expression increases.

CONCLUSION

Our findings demonstrate that PDLIM1 enables to alleviate gastric cancer progression and resistance to cisplatin via impeding DNA damage repair.

Korean Practice Guidelines for Gastric Cancer 2024: An Evidence-based, Multidisciplinary Approach (Update of 2022 Guideline)

Gastric cancer is one of the most common cancers in both Korea and worldwide. Since 2004, the Korean Practice Guidelines for Gastric Cancer have been regularly updated, with the 4th edition published in 2022. The 4th edition was the result of a collaborative work by an interdisciplinary team, including experts in gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology, and guideline development methodology. The current guideline is the 5th version, an updated version of the 4th edition. In this guideline, 6 key questions (KQs) were updated or proposed after a collaborative review by the working group, and 7 statements were developed, or revised, or discussed based on a systematic review using the MEDLINE, Embase, Cochrane Library, and KoreaMed database. Over the past 2 years, there have been significant changes in systemic treatment, leading to major updates and revisions focused on this area. Additionally, minor modifications have been made in other sections, incorporating recent research findings. The level of evidence and grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation system. Key factors for recommendation included the level of evidence, benefit, harm, and clinical applicability. The working group reviewed and discussed the recommendations to reach a consensus. The structure of this guideline remains similar to the 2022 version. Earlier sections cover general considerations, such as screening, diagnosis, and staging of endoscopy, pathology, radiology, and nuclear medicine. In the latter sections, statements are provided for each KQ based on clinical evidence, with flowcharts supporting these statements through meta-analysis and references. This multidisciplinary, evidence-based gastric cancer guideline aims to support clinicians in providing optimal care for gastric cancer patients.

Exploiting the role of O6-methylguanine-DNA-methyltransferase (MGMT) in gastrointestinal cancers

Gastrointestinal (GI) cancer is a prevalent disease and is recognized as the primary cause of cancer-related mortality globally. Therefore, there is an urgent need for novel diagnostic and treatment approaches for GC. The methylation of the O(6)-methylguanine DNA methyltransferase (MGMT) gene promoter is a significant factor in the development of colorectal cancer (CRC), namely in roughly 30-40% of cases where the cancer has spread. MGMT plays a role in the repair of DNA damage caused by methylating drugs like temozolomide (TMZ) and chloroethylating compounds like carmustine. As a result, it contributes to the resistance of chemotherapy when these agents are utilized. Although MGMT's role in the development of CRC is well established, its prognostic significance remains a subject of debate. Only a limited number of research have been conducted to examine the prognostic significance of MGMT methylation, yielding varying outcomes. This review explores the structural functions and repair processes of MGMT, focusing on the putative structural and functional significance of the N-terminal domain of MGMT. It also investigates the advancement of cancer treatment techniques that specifically target MGMT.

Reconsidering the Role of Radiotherapy for Inoperable Gastric Cancer: A Systematic Review of Gastric Radiotherapy Given With Definitive and Palliative Intent

AIMS

The role of radiotherapy (RT) for inoperable gastric cancer (IGC) is commonly low-dose, given reactively for symptoms (e.g. bleeding), in contrast to the oesophagus, where high quality evidence exists for higher doses of RT. This systematic review aims to evaluate the use of, and evidence for, definitive and high-dose palliative RT for IGC and whether a change in practice is warranted.

MATERIALS AND METHODS

Following registration with PROSPERO (CRD42022297080), MEDLINE, EMBASE and The Cochrane Library were searched in accordance with PRISMA standards for studies evaluating definitive (non-metastatic disease, BED10 >45Gy) or high-dose palliative RT (for symptom/local control, minimum BED10 >30Gy). A manual search of meeting proceedings and clinical trial registries was also performed.

RESULTS

31 studies were selected for analysis. 10 definitive studies totalling n = 354 patients receiving RT with 45-50.4Gy/25-28#, showed median overall survival ranging between 11 and 26.4 months, clinical complete response range 12%-45%, G3 gastrointestinal toxicity 0-31% (range) and RT completion rates ranging from 81% to 100%. 21 high-dose palliative studies (n = 955) mostly evaluated haemostatic control and reported 38 different RT regimens (most commonly 30Gy/10#). Bleeding response rate (RR) was 59.6%-90%, pain RR 45.5-100%, obstruction RR 52.9%-100%, G3 gastrointestinal toxicity <5% and RT completion 68%-100%. An additional American National Cancer Database review >4700 non metastatic IGC patients which combined both definitive and palliative doses found significant benefit to RT in addition to chemotherapy. Evidence regarding a dose-response relationship is conflicting, limited by retrospective data. Two studies report high quality -of-life (QOL) scores following gastric RT.

CONCLUSION

There is a body of mainly non-randomised, observational evidence showing high-dose RT is efficacious, safe and may maintain QOL for patients with IGC. A change in practice will require a prospective randomised controlled trial, which should explore the role of prophylactic, high-BED RT combined with optimal systemic therapy using modern IMRT techniques and RT quality assurance.

A Comprehensive and Comparative Review of Global Gastric Cancer Treatment Guidelines: 2024 Update

Differences in demographics, medical expertise, and patient healthcare resources across countries have led to significant variations in guidelines. In light of these differences, in this review, we aimed to explore and compare the most recent updates to gastric cancer treatment from five guidelines that are available in English. These English-version guidelines, which have been recently published and updated for journal publication, include those published in South Korea in 2024, Japan in 2021, China in 2023, the United States in 2024, and Europe in 2024. The South Korean and Japanese guidelines provide a higher proportion of content to endoscopic and surgical treatments, reflecting their focus on minimally invasive techniques, function-preserving surgeries, and systemic therapy. The Chinese guidelines provide recommendations addressing not only surgical approaches but also perioperative chemotherapy and palliative systemic therapy. Meanwhile, in the United States and European guidelines, a higher proportion of the content is dedicated to perioperative and palliative systemic therapy, aligning with their approaches to advanced-stage disease management. All guidelines address surgical and systemic chemotherapy treatments; however, the proportion and emphasis of content vary based on the patient distribution and treatment approaches specific to each country. With emerging research findings on gastric cancer treatment worldwide, the national guidelines are being progressively revised and updated. Understanding the commonalities and differences among national guidelines, along with the underlying evidence, can provide valuable insights into the treatment of gastric cancer.

Perioperative Treatment in Gastric Cancer: A Fast-Changing Field

Gastric cancer is the fifth most common cancer worldwide and its incidence is rising. Surgery is the only curative strategy and its association with perioperative chemotherapy is now standard treatment for most resectable tumors. Despite treatment advances, disease relapse is high, even in early stages, and continued improvement in curative treatment is imperative. With deeper knowledge of gastric cancer heterogeneity, molecular subtypes, and the tumor immune microenvironment, new standard treatment strategies may emerge in the near future. This paper provides a comprehensive review of the current treatment landscape in resectable gastric cancer and future perspectives for the next decade regarding new agents such as targeted therapies, immunotherapy, antibody-drug conjugates, and the combination of multiple treatment modalities.

Cross-sectional imaging of gastric cancer: pearls, pitfalls and lessons learned from multidisciplinary conference

Gastric cancer is rising in prevalence associated with high mortality, primarily due to late-stage detection, underscoring the imperative for early and precise diagnosis. Etiology involves an interplay of genetic susceptibilities and environmental factors with a prominent role of Helicobacter pylori infection. Due to its often-delayed symptom presentation, prompt and accurate diagnosis is necessary. A multimodal imaging approach, including endoscopic ultrasound (EUS), multi-detector computed tomography (MDCT), and magnetic resonance imaging (MRI) is critical for accurate staging. Each modality contributes unique advantages and limitations, highlighting the importance of integrating diagnostic strategy. Moreover, multidisciplinary conferences offer a vital collaborative platform, bringing together specialists from diverse fields for treatment planning. This synergistic approach not only enhances diagnostic precision but also improves patient outcome. This review highlights the critical role of imaging in diagnosis, staging, and management and advocates for interdisciplinary collaboration in early detection and comprehensive management of gastric cancer, aiming to reduce mortality.

Preoperative Chemoradiotherapy for Resectable Gastric Cancer

BACKGROUND

In Western countries, the current standard of care for resectable gastric cancer is perioperative chemotherapy. Preoperative chemoradiotherapy has been considered, but data are limited regarding this treatment as compared with perioperative chemotherapy alone.

METHODS

We conducted an international, phase 3 trial in which patients with resectable adenocarcinoma of the stomach or gastroesophageal junction were randomly assigned to receive preoperative chemoradiotherapy plus perioperative chemotherapy or perioperative chemotherapy alone (control). In both groups, patients received either epirubicin, cisplatin, and fluorouracil or fluorouracil, leucovorin, oxaliplatin, and docetaxel both before and after surgery; the preoperative-chemoradiotherapy group also received chemoradiotherapy (45 Gy in 25 fractions of radiation, plus fluorouracil infusion). The primary end point was overall survival, and secondary end points included progression-free survival, pathological complete response, toxic effects, and quality of life.

RESULTS

A total of 574 patients underwent randomization at 70 sites in Australasia, Canada, and Europe: 286 to the preoperative-chemoradiotherapy group and 288 to the perioperative-chemotherapy group. A higher percentage of patients in the preoperative-chemoradiotherapy group than in the perioperative-chemotherapy group had a pathological complete response (17% vs. 8%) and greater tumor downstaging after resection. At a median follow-up of 67 months, no significant between-group differences in overall survival or progression-free survival were noted. The median overall survival was 46 months with preoperative chemoradiotherapy and 49 months with perioperative chemotherapy (hazard ratio for death, 1.05; 95% confidence interval, 0.83 to 1.31), and the median progression-free survival was 31 months and 32 months, respectively. Treatment-related toxic effects were similar in the two groups.

CONCLUSIONS

The addition of preoperative chemoradiotherapy to perioperative chemotherapy did not improve overall survival as compared with perioperative chemotherapy alone among patients with resectable gastric and gastroesophageal junction adenocarcinoma. (Funded by the National Health and Medical Research Council and others; TOPGEAR ClinicalTrials.gov number, NCT01924819.).

From twilight to starlight? Debating the role of chemoradiotherapy in gastric cancer in the D2 dissection era

Patients affected by resectable locally advanced gastric cancer (GC) should receive perioperative chemotherapy as a standard of care. However, an additional benefit of adjuvant chemoradiation (CRT) has been negated by modern trials in the era of extended surgical dissection, and CRT is currently only considered on an individual basis in case of suboptimal resection. However, the dismal prognosis of GC and the modest treatment completion rates of perioperative chemotherapy have pushed to reconsider CRT, particularly as a preoperative treatment, in light of modern treatment techniques, advances in the understanding of the immune landscape and development of targeted agents. The aim of this review is to critically assess the historical role of CRT, the limitations of current evidence and to debate its potential role in an integrated neoadjuvant strategy for patients with resectable GC.

SEOM-GEMCAD-TTD clinical guideline for the diagnosis and treatment of gastric cancer (2023)

Gastric cancer (GC) is the fifth most common cancer worldwide with a varied geographic distribution and an aggressive behavior. In Spain, the incidence is lower and GC represents the tenth most frequent tumor and the seventh cause of cancer mortality. Molecular biology knowledge allowed to better profile patients for a personalized therapeutic approach. In the localized setting, the multidisciplinary team discussion is fundamental for planning the therapeutic approach. Endoscopic resection in very early stage, perioperative chemotherapy in locally advanced tumors, and chemoradiation + surgery + adjuvant immunotherapy for the GEJ are current standards. For the metastatic setting, biomarker profiling including Her2, PD-L1, MSS status is needed. Chemotherapy in combination with checkpoint inhibitors had improved the outcomes for patients with PD-L1 expression. Her2 positive patients should receive antiHer2 therapy added to chemotherapy. We describe the different evidences and recommendations based on the literature.

Targeting NUF2 suppresses gastric cancer progression through G2/M phase arrest and apoptosis induction

BACKGROUND

Gastric cancer (GC), a malignant tumor with poor prognosis, is one of the leading causes of cancer-related deaths worldwide; consequently, identifying novel therapeutic targets is crucial for its corresponding treatment. NUF2 , a component of the NDC80 kinetochore complex, promotes cancer progression in multiple malignancies. Therefore, this study aimed to explore the potential of NUF2 as a therapeutic target to inhibit GC progression.

METHODS

Clinical samples were obtained from patients who underwent radical resection of GC at Lanzhou University Second Hospital from 2016 to 2021. Cell count assays, colony formation assays, and cell-derived xenotransplantation (CDX) models were used to determine the effects of NUF2 on GC progression. Flow cytometry was used to detect the effect of NUF2 or quercetin on cell cycle progression and apoptosis. A live-cell time-lapse imaging assay was performed to determine the effect of NUF2 on the regulation of mitotic progression. Transcriptomics was used to investigate the NUF2 -associated molecular mechanisms. Virtual docking and microscale thermophoresis were used to identify NUF2 inhibitors. Finally, CDX, organoid, and patient-derived xenograft (PDX) models were used to examine the efficacy of the NUF2 inhibitor in GC.

RESULTS

NUF2 expression was significantly increased in GC and was negatively correlated with prognosis. The deletion of NUF2 suppressed GC progression both in vivo and in vitro . NUF2 significantly regulated the mitogen-activated protein kinase (MAPK) pathway, promoted G2/M phase transition, and inhibited apoptosis in GC cells. Additionally, quercetin was identified as a selective NUF2 inhibitor with low toxicity that significantly suppressed tumor growth in GC cells, organoids, CDX, and PDX models.

CONCLUSIONS

Collectively, NUF2 -mediated G2/M phase transition and apoptosis inhibition promoted GC progression; additionally, NUF2 inhibitors exhibited potent anti-GC activity. This study provides a new strategy for targeting NUF2 to suppress GC progression in clinical settings.

Report from the 25th Annual Western Canadian Gastrointestinal Cancer Consensus Conference on Gastric and Gastroesophageal Cancers, Winnipeg, Manitoba, 26-27 October 2023

The 25th Annual Western Canadian Gastrointestinal Cancer Consensus Conference (WCGCCC) was held in Winnipeg, Manitoba, on 26-27 October 2023. The WCGCCC is an interactive multidisciplinary conference that was attended by healthcare professionals from across Western Canada (British Columbia, Alberta, and Manitoba) who are involved in the care of patients with gastrointestinal cancer. Surgical, medical, and radiation oncologists; pathologists; oncology nurses; pharmacists; and a family physician in oncology (FPO) participated in presentation and discussion sessions for the purpose of developing the recommendations presented here. This consensus statement addresses current issues in the management of gastroesophageal cancers.

Survival Outcomes in Patients with Resectable Gastric Cancer Treated with Total Neoadjuvant Therapy

BACKGROUND

Perioperative chemotherapy has become the standard of care for locally advanced gastric cancer. Total neoadjuvant therapy (TNT), including both chemotherapy and chemoradiation, is utilized in other gastrointestinal malignancies. We determined survival in a contemporary cohort of gastric cancer patients treated with TNT.

METHODS

Using a prospective institutional database, patients diagnosed with cT2-4 or cN+ gastric adenocarcinoma (January 2012 to June 2022) who underwent staging laparoscopy, received TNT, and underwent gastrectomy were identified. Overall survival (OS) and disease-specific survival (DSS) were determined using standard statistical methods.

RESULTS

The study included 203 patients. The most common TNT sequence was induction chemotherapy followed by chemoradiation (n = 186 [91.6%]). A total of 195 (96.1%) patients completed planned neoadjuvant treatments. Surgery included total gastrectomy in 108 (53.2%), extended (D1+/D2) lymphadenectomy in 193 (95.1%), and adjacent organ resection in 19 (9.4%) patients. Pathologic complete response (pCR) was achieved in 32 (15.8%) patients. The 5-year OS rate was 65.2% (95% confidence interval [CI] 57.8-73.5%), and the 5-year DSS rate was 70.8% (95% CI 63.6-78.9%) in the study cohort. Among patients with pCR, the 5-year OS rate was 89.1% (95% CI 78.1-100.0%), and the 5-year DSS rate was 96.9% (95% CI 91-100%). Posttreatment pathologic N and M stages were the strongest prognostic indicators associated with both OS and DSS.

CONCLUSIONS

Total neoadjuvant therapy for resectable gastric cancer is associated with a high rate of treatment completion and promising survival outcomes. Prospective comparisons with perioperative treatment are needed to identify patients most likely to benefit from TNT.

Comparison of treatment strategies based on clinical and pathological nodal status in resectable gastric adenocarcinoma

BACKGROUND

To determine the optimal multimodal treatment strategy between perioperative chemotherapy (PEC), postoperative chemoradiation therapy (POCR), and postoperative chemotherapy (POC) in resected gastric cancer (GC) patients based on nodal status.

METHODS

In this retrospective analysis, the National Cancer Database was used to identify resected non-metastatic GC (2006-2016). Patients were stratified by clinical nodal status-negative (cLN-) and positive (cLN+). In patients with cLN- disease who underwent upfront resection and were upstaged to pathological LN+, overall survival (OS) was compared between POC and POCR. In patients with cLN- and cLN+ disease, OS was compared between PEC, POCR, and POC. Kaplan-Meier survival estimate, log-rank test, and multivariable Cox proportional hazards analysis were performed.

RESULTS

We identified 7827 patients (cLN- 4828; cLN+ 2999). On multivariable analysis in patients with cLN- disease who underwent upfront resection (n = 4314) and were upstaged to pLN+ disease (70%), POCR (n = 2300, aHR 0.78, 95% CI 0.70-0.87, p < 0.001) was associated with improved OS compared to POC (n = 907). No significant difference was noted between POCR (n = 766, aHR 1.11, 95% CI 0.88-1.40, p = 0.39) and POC (n = 341) in patients with pLN- disease. On multivariable analysis in all patients with cLN- disease, POCR (n = 3066) was significantly associated with improved OS (aHR 0.84, 95% CI 0.75-0.92, p < 0.01) compared to POC (n = 1248). No significant difference was noted between POCR (aHR 1.0, 95% CI 0.70-1.01, p = 0.958) and PEC (n = 514). These results remained consistent in patients with cLN+ disease (POCR = 1602, POC = 720, PEC = 677).

CONCLUSION

Postoperative chemoradiation is associated with improved survival in GC patients upstaged from clinically node-negative disease to pathologically node-positive disease. Negative clinical nodal disease status is not a reliable indicator of pathological nodal disease.

Gastric cancer-Epidemiology, modifiable and non-modifiable risk factors, challenges and opportunities: An updated review

Gastric cancer represents a significant global health challenge due to its high mortality and incidence rates, particularly in Eastern Asia, Eastern Europe, and South America. This comprehensive review synthesizes the latest epidemiological data and explores both modifiable and non-modifiable risk factors associated with gastric cancer, aiming to delineate the multifactorial etiology of this disease. Modifiable risk factors include Helicobacter pylori infection, obesity, dietary habits, smoking and alcohol consumption, whereas nonmodifiable factors comprise genetic predispositions, age, family history and male gender. The interplay of these factors significantly impacts the risk and progression of gastric cancer, suggesting potential preventive strategies. The challenges in treating gastric cancer are considerable, largely because of the late-stage diagnosis and the heterogeneity of the disease, which complicate effective treatment regimens. Current treatment strategies involve a combination of surgery, chemotherapy, radiotherapy, and targeted therapies. The FLOT regimen (5-FU, Leucovorin, Oxaliplatin and Docetaxel) is now a standard for resectable cases in Europe and the US, showing superior survival and response rates over ECF and ECX regimens. For HER2-positive gastric cancer, trastuzumab combined with chemotherapy improves overall survival, as demonstrated by the ToGA trial. Additionally, immune checkpoint inhibitors like pembrolizumab and nivolumab offer promising results. However, the five-year survival rate remains low, underscoring the urgency for improved therapeutic approaches. Recent advancements in molecular biology and cancer genomics have begun to pave the way for personalized medicine in gastric cancer care, focusing on molecular targeted therapies and immunotherapy. This review also highlights the critical need for better screening methods that could facilitate early detection and treatment, potentially improving the prognosis. By integrating epidemiological insights with new therapeutic strategies, this article aims to thoroughly understand of gastric cancer's dynamics and outline a framework for future research and clinical management, advocating for a multidisciplinary approach to tackle this formidable disease.

Impact of Minimally Invasive Surgery on Early and Late Outcomes of Patients With Gastric Cancer Treated Using Neoadjuvant Chemotherapy

BACKGROUND

Gastric cancer is the fifth most common neoplasm and the third leading cause of cancer-related death worldwide. Neoadjuvant chemotherapy is recommended for Stages II-III resectable tumors, but the comparative effectiveness of minimally invasive surgery (MIS) versus open gastrectomy (OG) post-neoadjuvant therapy has not been adequately investigated.

METHODS

A retrospective cohort analysis was performed on patients with clinical Stage II and III gastric adenocarcinoma who underwent neoadjuvant chemotherapy followed by either MIS or OG between 2007 and 2020. Propensity score matching was utilized to compare the clinical and surgical outcomes, morbidity, and mortality, and the influence of MIS on 3-year survival rates was evaluated.

RESULTS

After matching, no statistical differences in clinical aspects were noted between the two groups. MIS was associated with increased D2 lymphadenectomy, curative intent, and complete neoadjuvant therapy. Furthermore, this therapeutic approach resulted in reduced transfusion rates and shorter hospital stays. Nonetheless, no significant differences were observed in global, clinical, or surgical complications or mortality between the two groups. Weight loss emerged as a significant risk factor for complications, but MIS did not independently affect survival rates. Extended resection and higher American Society of Anesthesiology scores were independent predictors of reduced survival.

CONCLUSION

MIS after neoadjuvant chemotherapy for gastric cancer appears to be a viable option, with oncological outcomes comparable to those of OG, less blood loss, and shorter hospital stays. Although MIS did not independently affect long-term survival, it offered potential benefits in terms of postoperative recovery and morbidity. Further studies are needed to validate these findings, especially across diverse populations.

Perioperative immune checkpoint inhibitors combined with chemotherapy versus chemotherapy for locally advanced, resectable gastric or gastroesophageal junction adenocarcinoma: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Immunotherapy in combination with chemotherapy has been approved as an initial treatment strategy for unresectable advanced gastric cancer (GC). However, the efficacy of adding immunotherapy to perioperative chemotherapy in locally advanced resectable gastric or gastroesophageal junction adenocarcinoma (GC/GEJC) remains uncertain. Therefore, a meta-analysis of randomized controlled trials (RCTs) was performed to compare the effectiveness of perioperative immune checkpoint inhibitors (ICIs) plus chemotherapy versus chemotherapy alone in patients with locally advanced resectable GC/GEJC.

METHODS

A comprehensive search of online databases was conducted to identify RCTs published until November 30, 2023. Odds ratios (ORs) with 95% confidence interval (CI) were calculated for primary outcomes, including R0 resection rate, D2 lymphadenectomy, pathologic complete response (pCR), and treatment-related adverse events (TRAEs).

RESULTS

A total of 2718 patients from five RCTs (six reports) were included in the analysis. The pooled ORs of R0 resection rate and D2 lymphadenectomy demonstrated that combination therapy with ICIs showed no significant difference compared to chemotherapy alone. However, the addition of ICIs significantly improved pCR rates (OR = 3.43, 95 % CI 2.61-4.50, p < 0.0001). There were no significant differences observed in the incidence of any grade TRAEs and grade 3-4 TRAEs. However, ICIs combination therapy was associated with significantly higher incidences of any grade irAEs (OR = 4.03, 95 % CI: 2.70-6.00, p < 0.0001), as well as grade 3-4 irAEs (OR = 4.51, 95 % CI: 2.27-8.97, p < 0.0001).

CONCLUSIONS

This study represents the first meta-analysis to demonstrate that perioperative combination therapy with ICIs yields superior pCR rates for patients with locally advanced GC/GEJC compared to chemotherapy.

A transformer-based deep learning model for early prediction of lymph node metastasis in locally advanced gastric cancer after neoadjuvant chemotherapy using pretreatment CT images

Background

Early prediction of lymph node status after neoadjuvant chemotherapy (NAC) facilitates promptly optimization of treatment strategies. This study aimed to develop and validate a deep learning network (DLN) using baseline computed tomography images to predict lymph node metastasis (LNM) after NAC in patients with locally advanced gastric cancer (LAGC).

Methods

A total of 1205 LAGC patients were retrospectively recruited from three hospitals between January 2013 and March 2023, constituting a training cohort, an internal validation cohort, and two external validation cohorts. A transformer-based DLN was developed using 3D tumor images to predict LNM after NAC. A clinical model was constructed through multivariate logistic regression analysis as a baseline for subsequent comparisons. The performance of the models was evaluated through discrimination, calibration, and clinical applicability. Furthermore, Kaplan-Meier survival analysis was conducted to assess overall survival (OS) of LAGC patients at two follow-up centers.

Findings

The DLN outperformed the clinical model and demonstrated a robust performance for predicting LNM in the training and validation cohorts, with areas under the curve (AUCs) of 0.804 (95% confidence interval [CI], 0.752-0.849), 0.748 (95% CI, 0.660-0.830), 0.788 (95% CI, 0.735-0.835), and 0.766 (95% CI, 0.717-0.814), respectively. Decision curve analysis exhibited a high net clinical benefit of the DLN. Moreover, the DLN was significantly associated with the OS of LAGC patients [Center 1: hazard ratio (HR), 1.789, P < 0.001; Center 2:HR, 1.776, P = 0.013].

Interpretation

The transformer-based DLN provides early and effective prediction of LNM and survival outcomes in LAGC patients receiving NAC, with promise to guide individualized therapy. Future prospective multicenter studies are warranted to further validate our model.

Funding

National Natural Science Foundation of China (NO. 82373432, 82171923, 82202142), Project Funded by China Postdoctoral Science Foundation (NO. 2022M720857), Regional Innovation and Development Joint Fund of National Natural Science Foundation of China (NO. U22A20345), National Science Fund for Distinguished Young Scholars of China (NO. 81925023), Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application (NO. 2022B1212010011), High-level Hospital Construction Project (NO. DFJHBF202105), Natural Science Foundation of Guangdong Province for Distinguished Young Scholars (NO. 2024B1515020091).

Neoadjuvant chemotherapy for resectable gastric cancer is associated with better outcomes than neoadjuvant chemoradiation

INTRODUCTION

National Comprehensive Cancer Network Guidelines recommend neoadjuvant chemotherapy (CTx) or chemoradiation (CRTx) for advanced resectable gastric cancer, irrespective of the tumor location. The aim of this study is to compare survival benefits between neoadjuvant CTx and CRTx using the National Cancer Database (NCDB).

METHODS

Using the NCDB, we retrospectively reviewed patients who underwent gastrectomy after neoadjuvant CRTx or CTx between 2004 and 2018.

RESULTS

The cohort included 14 266 patients, with 6458 (45.3%) receiving neoadjuvant CTx and 7808 (54.7%) receiving neoadjuvant CRTx. Both treatment groups exhibited significant differences in various demographic and clinical factors, including sex, age, race, tumor locations, stages, and adjuvant treatment (all p < 0.001). While the complete pathological response was more prevalent in the CRTx group (p < 0.001), overall survival (OS) was significantly extended in the CTx group (p < 0.001). Subgroup survival analyses, accounting for tumor location and clinical/pathological stage, consistently revealed longer OS in the CTx group (p < 0.001). The direct comparison showed an approximately 20%-30% improved 5-year OS in the CTx group across the majority of American Joint Committee on Cancer (AJCC) T/N category tables. Multivariate analysis confirmed neoadjuvant CTx was an independent protective factor (hazard ratio = 0.811; p < 0.001). A nomogram for OS based on multivariate analysis was also proposed, revealing a significant improvement in the c-index compared to the current AJCC staging (0.654 vs. 0.596).

CONCLUSIONS

Patients undergoing neoadjuvant CRTx demonstrated significantly shorter survival compared to patients undergoing CTx at the same stage. The current AJCC staging may lead to an overestimation of survival in patients with neoadjuvant CRTx.

Evaluation of the endoscopic cure criteria in patients undergoing surgery for early gastric cancer

BACKGROUND AND OBJECTIVES

Gastric cancer (GC) prognosis is influenced by the extent of the tumor, lymph node involvement (LNM), and metastasis. Endoscopic resection (ER) or gastrectomy with lymphadenectomy are standard treatments for early GC (EGC). This study evaluated LNM frequency according to eCura categories, clinicopathological characteristics, disease-free (DFS), and overall (OS) survival rates.

METHODS

We included EGC patients who underwent curative gastrectomy between 2009 and 2020 from our single-center database. Anatomopathological and clinical reports were reviewed to analyze eCura categories.

RESULTS

We included 160 EGC patients who underwent gastrectomy with eCura categories A, B, and C, comprising 26.3%, 13.8%, and 60%, respectively. Baseline clinical characteristics showed no intergroup disparities. LNM incidence for A, B, and C was 4.8%, 18.2%, and 19.8%. When evaluating the criteria for ER and its association with eCura categories, we found that 95.2% of eCura A and 100% of eCura B patients had classic or expanded criteria for ER. On the other hand, 97.9% of eCura C patients were referred to surgical resection. Multivariate analysis demonstrated that lymphatic (OR = 5.57, CI95% = 1.45-21.29, p = 0.012) and perineural (OR = 15.8, CI95% = 1.39-179.88, p = 0.026) invasions were associated with a higher risk of LNM. No significant differences in DFS or OS were found among eCura categories.

CONCLUSION

The eCura categories were associated with the occurrence of LNM. In most patients, those with classic and expanded indication criteria for ER were classified as eCura A and B.

Information Needs in Patients with Potentially Curable Gastroesophageal Cancer

INTRODUCTION

Gastroesophageal cancer patients' information needs remain understudied, despite their complex treatment trajectories.

METHODS

This study examined the (i) information needs of patients with or without postoperative complications, (ii) information needs of male and female patients, and (iii) the association between information needs and health-related quality of life (HR-QoL) following gastroesophageal cancer surgery. Patients completed the EORTC-QLQ-INFO25, QLQ-C30, and QLQ-OG25 questionnaires before and after curative surgery. Five information needs domains were investigated: information about the disease, about treatments, about medical tests, about things patients can do to help themselves, and overall helpfulness. Additionally, HR-QoL domains global health status, eating restrictions, and anxiety were explored.

RESULTS

A total of 132 patients completed the questionnaires at baseline, 216 patients at 6-12 months, 184 patients at 18-24 months, and 163 patients at 3-5 years post-operation. There were no significant differences in information needs between patients with or without complications or between male and female patients. Patients with a higher global health status found the information more helpful at 6-12 months (p < 0.001), 18-24 months (p < 0.001), and 3-5 years (p < 0.001) postoperatively, as did patients who experienced more anxiety at 18-24 months (p = 0.009) and 3-5 years (p < 0.001).

CONCLUSION

Gastroesophageal cancer patients, regardless of sex or postoperative complications, have consistent information needs, yet those with higher global health status and elevated anxiety levels find the information particularly helpful, emphasizing the importance of tailored communication strategies.

Surgical Techniques and Related Perioperative Outcomes After Robot-assisted Minimally Invasive Gastrectomy (RAMIG): Results From the Prospective Multicenter International Ugira Gastric Registry

OBJECTIVE

To gain insight into the global practice of robot-assisted minimally invasive gastrectomy (RAMIG) and evaluate perioperative outcomes using an international registry.

BACKGROUND

The techniques and perioperative outcomes of RAMIG for gastric cancer vary substantially in the literature.

METHODS

Prospectively registered RAMIG cases for gastric cancer (≥10 per center) were extracted from 25 centers in Europe, Asia, and South-America. Techniques for resection, reconstruction, anastomosis, and lymphadenectomy were analyzed and related to perioperative surgical and oncological outcomes. Complications were uniformly defined by the Gastrectomy Complications Consensus Group.

RESULTS

Between 2020 and 2023, 759 patients underwent total (n=272), distal (n=465), or proximal (n=22) gastrectomy (RAMIG). After total gastrectomy with Roux-en-Y-reconstruction, anastomotic leakage rates were 8% with hand-sewn (n=9/111) and 6% with linear stapled anastomoses (n=6/100). After distal gastrectomy with Roux-en-Y (67%) or Billroth-II-reconstruction (31%), anastomotic leakage rates were 3% with linear stapled (n=11/433) and 0% with hand-sewn anastomoses (n=0/26). Extent of lymphadenectomy consisted of D1+ (28%), D2 (59%), or D2+ (12%). Median nodal harvest yielded 31 nodes (interquartile range: 21-47) after total and 34 nodes (interquartile range: 24-47) after distal gastrectomy. R0 resection rates were 93% after total and 96% distal gastrectomy. The hospital stay was 9 days after total and distal gastrectomy, and was median 3 days shorter without perianastomotic drains versus routine drain placement. Postoperative 30-day mortality was 1%.

CONCLUSIONS

This large multicenter study provided a worldwide overview of current RAMIG techniques and their respective perioperative outcomes. These outcomes demonstrated high surgical quality, set a quality standard for RAMIG, and can be considered an international reference for surgical standardization.

Who would be the winner? A prognostic nomogram for predicting the benefit of postoperative radiotherapy ± chemotherapy in patients with locally advanced gastric cancer: TROD-02-01 study

OBJECTIVES

We aimed to develop a basic, easily applicable nomogram to improve the survival prediction of the patients with stage II/III gastric cancer (GC) and to select the best candidate for postoperative radiotherapy (RT).

METHODS

In this multicentric trial, we retrospectively evaluated the data of 1597 patients with stage II/III GC after curative gastrectomy followed by postoperative RT ± chemotherapy (CT). Patients were divided into a training set (n = 1307) and an external validation set (n = 290). Nomograms were created based on independent predictors identified by Cox regression analysis in the training set. The consistency index (C-index) and the calibration curve were used to evaluate the discriminative ability and accuracy of the nomogram. A nomogram was created based on the predictive model and the identified prognostic factors to predict 5-year cancer-specific survival (CSS) and progression-free survival (PFS).

RESULTS

The multivariate Cox model recognized lymph node (LN) involvement status, lymphatic dissection (LD) width, and metastatic LN ratio as covariates associated with CSS. Depth of invasion, LN involvement status, LD width, metastatic LN ratio, and lymphovascular invasion were the factors associated with PFS. Calibration of the nomogram predicted both CSS and PFS corresponding closely with the actual results. In our validation set, discrimination was good (C-index, 0.76), and the predicted survival was within a 10% margin of ideal nomogram.

CONCLUSIONS

In our relatively large cohort, we created and validated both CSS and PFS nomograms that could be useful for underdeveloped or developing countries rather than Korea and Japan, where the D2 gastrectomy is routinely performed. This could serve as a true map for oncologists who must make decisions without an experienced surgeon and a multidisciplinary tumor board.

Perioperative intraperitoneal plus systemic chemotherapy and cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for gastric cancer: phase Ib/II single-arm prospective study

BACKGROUND

In gastric cancer, peritoneal metastasis is the most common form of metastasis and leads to dismal prognosis. We aimed to evaluate the safety and efficacy of combining perioperative intraperitoneal (IP) plus systemic chemotherapy, cytoreductive surgery (CRS), and hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with gastric cancer with limited peritoneal metastasis or even after reducing peritoneal tumor burden by upfront IP chemotherapy.

METHOD

Patients were enrolled in phase Ib in a 3 + 3 dose escalation of IP paclitaxel plus a fixed dose of IP cisplatin and oral S-1. In phase II, patients were managed according to the peritoneal cancer index (PCI) by diagnostic laparoscopy. For patients with a PCI of >12, upfront IP and systemic chemotherapy were given. Patients with a PCI of ≤12 or reduced to ≤12 after upfront chemotherapy underwent CRS with HIPEC. The primary endpoints were safety and the recommended phase II dose (RP2D) confirmation for phase Ib and the 1-year overall survival rate for phase II.

RESULTS

The RP2D was defined as IP 175 mg/m2 paclitaxel and 60 mg/m2 cisplatin and oral 70 mg/m2/day S-1 for 14 days. A total of 22 patients were included. After CRS with HIPEC, there were no grade 3 or higher complications. The median hospital stay was 7 days (range, 6-11). The median overall and progression-free survival were 27.3 months (95% CI, 14.4 to not estimable) and 12.6 months (95% CI, 7.7-14.5), respectively. One-year overall and progression-free survival rates were 81.0% (95% CI, 65.8-99.6) and 54.5% (95% CI, 37.2-79.9), respectively.

CONCLUSION

A combination of IP plus systemic chemotherapy, CRS, and HIPEC was safe and resulted in good survival outcomes.

Gastric Cancer Survivorship: Multidisciplinary Management, Best Practices and Opportunities

PURPOSE

Gastric cancer is the 5th most common malignancy worldwide. As early detection increases and treatments for gastric cancer improve, the number of gastric cancer survivors grows.

METHODS

Here, we review the diagnosis and management of gastric cancer and discuss important considerations for gastric cancer survivorship including cancer surveillance, weight loss, malnutrition, fatigue, specific complications related to surgery and radiation, quality of life in gastric cancer survivorship, health behavior, and models of survivorship.

RESULTS

Multimodality therapy with chemotherapy and surgery can result in chronic toxicities in multiple organ systems. This emphasizes the need for a multidisciplinary survivorship care model including cancer surveillance, management of chronic toxicities, and optimization of modifiable risk factors with long-term involvement of appropriate providers.

CONCLUSION

Adequately caring for gastric cancer survivors requires a coordinated, multidisciplinary approach.

Locally Advanced Gastric Cancer Management: A Cost-Effectiveness Analysis

Across the nation, patients with locally advanced gastric cancer (LAGC) are managed with modalities including upfront surgery (US) and perioperative chemotherapy (PCT). Preoperative therapies have demonstrated survival benefits over US and thus long-term outcomes are expected to vary between the options. However, as these 2 modalities continue to be regularly employed, we sought to perform a decision analysis comparing the costs and quality-of-life associated with the treatment of patients with LAGC to identify the most cost-effective option. We designed a decision tree model to investigate the survival and costs associated with the most commonly utilized management modalities for LAGC in the United States: US and PCT. The tree described costs and treatment strategies over a 6-month time horizon. Costs were derived from 2022 Medicare reimbursement rates using the third-party payer perspective for physicians and hospitals. Effectiveness was represented using quality-adjusted life-years (QALYs). One-way, two-way, and probabilistic sensitivity analyses were utilized to test the robustness of our findings. PCT was the most cost-effective treatment modality for patients with LAGC over US with a cost of $40,792.16 yielding 3.11 QALYs. US has a cost of $55,575.57 while yielding 3.15 QALYs; the incremental cost-effectiveness ratio (ICER) was $369,585.25. One-way and two-way sensitivity analyses favored PCT in all variations of variables across their standard deviations. Across 100,000 Monte Carlo simulations, 100% of trials favored PCT. In our model simulating patients with LAGC, the most cost-effective treatment strategy was PCT. While US demonstrated improved QALYs over PCT, the associated cost was too great to justify its use.

Esophagogastric Cancer: The Current Role of Radiation Therapy

Radiation therapy is an effective treatment modality in the management of patients with esophageal cancer regardless of tumor location (proximal, middle, or distal esophagus) or histology (squamous cell vs adenocarcinoma). The addition of neoadjuvant CRT to surgery in patients who are surgical candidates has consistently shown a benefit in terms of locoregional recurrence, pathologic downstaging, and overall survival. For patients who are not surgical candidates, CRT has a role as definitive treatment.

Role of Preoperative Radiation Therapy for Resectable Gastric Cancer

PURPOSE

While surgery is the primary curative treatment for resectable gastric and gastroesophageal junction (GEJ) cancer, rates of locoregional and distant recurrence remain high with surgery alone, especially in more advanced disease. Multimodal approaches with perioperative therapy including chemotherapy and/or radiation therapy (RT) have thus evolved as ways to reduce the rates of disease recurrence and improve survival outcomes. This review article provides a comprehensive literature review on the role of preoperative RT for resectable gastric and GEJ cancer.

METHODS

A literature review on the role of preoperative RT for resectable gastric and GEJ cancer was conducted.

RESULTS

Preoperative RT has the potential to facilitate tumor downstaging and improved R0 resection, allowing for better locoregional control and thereby survival. For resectable locally advanced GEJ cancer, preoperative chemoradiotherapy (CRT) is currently a standard of care option along with perioperative chemotherapy, based on evidence from randomized trials. In resectable gastric cancer, however, the role of preoperative CRT is less defined with no randomized data to date, although phase II single-arm studies have shown promising results. Current standard of care for gastric cancer remains perioperative chemotherapy, with consideration for preoperative CRT in select cases.

CONCLUSION

Results from ongoing and future randomized controlled trials are expected to help define the role of preoperative CRT compared to perioperative chemotherapy alone as well as postoperative CRT for gastric and GEJ cancer.

Patient- and system-level factors associated with racial/ethnic disparities in the delivery of guideline-concordant therapy among US patients with gastric cancer

BACKGROUND

Disparities in gastric cancer (GC) outcomes show a higher disease burden among minorities. We aimed to evaluate the associations between sociodemographic and system-level factors and guideline-concordant treatment among GC patients.

METHODS

Cohort study with GC patients in the National Cancer Data Base (2006-2018) treated with upfront resection or neoadjuvant therapy (NAT). We used logistic regression to identify associations between deviations from guideline-concordant therapy and patient- and system-level factors, and Cox regression models to assess risk of death.

RESULTS

The cohort included 43 597 GC patients treated with endoscopic resection (8.9%), surgery only (47.1%), surgery and adjuvant therapy (20.6%), or NAT followed by surgery (23.5%). A total of 31 470 patients (72.2%) received guideline-concordant therapy. Relative to Non-Hispanic Whites (NHWs), Non-Hispanic Blacks (NHBs) (odds ratio [OR] 1.19, [95% confidence intervals 1.10-1.28]) and Asian/Pacific Islanders (APIs) (OR 1.12 [1.03-1.23]) had an increased risk of deviations from treatment guidelines. Medicare/Medicaid increased the risk of deviations while treatment at high-volume facilities decreased its risk for all races/ethnicities. Deviations from guidelines were associated with an increased risk of death (hazard ratio 1.56 [1.50-1.63].

CONCLUSIONS

Racial disparities in the delivery of guideline-concordant therapy among GC patients are affected by several sociodemographic factors at the patient- and system-level.

Neoadjuvant and/or adjuvant chemotherapy for gastric cancer patients with microsatellite instability or deficient mismatch repair: a systematic review and meta-analysis study protocol

INTRODUCTION

Whether gastric cancer (GC) patients with deficient mismatch repair or microsatellite instability-high (dMMR/MSI-H) benefit from perioperative (neoadjuvant and/or adjuvant) chemotherapy is controversial. This protocol delineates the planned scope and methods for a systematic review and meta-analysis that aims to compare the efficacy of perioperative chemotherapy with surgery alone in resectable dMMR/MSI-H GC patients.

METHODS AND ANALYSIS

This study protocol is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols-P guideline. PubMed, Embase, Cochrane (CENTRAL), and the Web of Science databases will be searched, supplemented by a secondary screening of relevant records. Both randomised controlled trials and non-randomised studies will be included in this study. The primary and secondary outcomes under scrutiny will be overall survival, disease-free survival and progression-free survival. Two reviewers will independently screen studies, extract data and assess the risk of bias. We will analyse different treatment settings (eg, neoadjuvant or adjuvant or combined as perioperative chemotherapies) separately and conduct sensitivity analyses.

ETHICS AND DISSEMINATION

No ethics approval is required for this systematic review and meta-analysis, as no individual patient data will be collected. The findings of our study will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42023494276.

UBE2L3 expression in human gastric cancer and its clinical significance

PURPOSE

Gastric cancer (GC) is prevalent as one of the most common malignant tumors globally, with a particularly high incidence in China. The role of UBE2L3 in the initiation and progression of various cancers has been well documented, but its specific significance in GC is not yet fully elucidated. The objective of this study is to examine the expression and importance of UBE2L3 in human gastric cancer tissues.

METHODS

Immunohistochemical staining and survival analysis were conducted on 125 cases of GC. Western blot and quantitative real-time polymerase chain reaction (qRT-PCR) were employed to assess the expression of UBE2L3 in GC cell lines. Cell lines with UBE2L3 knockdown and overexpression were cultured through lentivirus transfection and subsequently assessed using Western blot analysis. The involvement of UBE2L3 in the proliferation, invasion, and apoptosis of GC cells was confirmed through in vitro experiments, and its capacity to facilitate tumor growth was also validated in in vivo studies.

RESULTS

The up-regulation of UBE2L3 expression was observed in GC, and its high expression was found to be significantly associated with the degree of differentiation (χ2 = 6.153, P = 0.0131), TNM stage (χ2 = 6.216, P = 0.0447), and poor overall survival. In vitro, UBE2L3 has been shown to enhance functions in GC cell lines, such as promoting proliferation and invasion, and inhibiting apoptosis. In vivo experiments have validated the role of UBE2L3 in promoting tumor growth.

CONCLUSIONS

The findings of our study demonstrate the significant involvement of UBE2L3 in the pathogenesis and advancement of gastric cancer, suggesting its potential as a therapeutic target.

State of the scientific evidence and recommendations for the management of older patients with gastric cancer

Gastric cancer is one of the most frequent and deadly tumours worldwide. However, the evidence that currently exists for the treatment of older adults is limited and is derived mainly from clinical trials in which older patients are poorly represented. In this article, a group of experts selected from the Oncogeriatrics Section of the Spanish Society of Medical Oncology (SEOM), the Spanish Group for the Treatment of Digestive Tumours (TTD), and the Spanish Multidisciplinary Group on Digestive Cancer (GEMCAD) reviews the existing scientific evidence for older patients (≥65 years old) with gastric cancer and establishes a series of recommendations that allow optimization of management during all phases of the disease. Geriatric assessment (GA) and a multidisciplinary approach should be fundamental parts of the process. In early stages, endoscopic submucosal resection or laparoscopic gastrectomy is recommended depending on the stage. In locally advanced stage, the tolerability of triplet regimens has been established; however, as in the metastatic stage, platinum- and fluoropyrimidine-based regimens with the possibility of lower dose intensity are recommended resulting in similar efficacy. Likewise, the administration of trastuzumab, ramucirumab and immunotherapy for unresectable metastatic or locally advanced disease is safe. Supportive treatment acquires special importance in a population with different life expectancies than at a younger age. It is essential to consider the general state of the patient and the psychosocial dimension.