The roles of chemotherapy and surgery in gastric carcinoma and the influence of prognostic factors on survival

Downregulation of 425G>a variant of calcium-binding protein S100A14 associated with poor differentiation and prognosis in gastric cancer

PURPOSE

Altered level of S100 calcium-binding proteins is involved in tumor development and progression. However, their role in gastric cancer (GC) is not well documented. We investigated the expression pattern of S100 proteins and differentiation or prognosis as well as possible mechanisms in GC.

METHODS

RT-PCR, Western blot analysis, and immunohistochemistry were used to determine the mRNA and protein expression of S100 family genes in GC. The polymorphisms of promoter and 5'-UTR of S100A14 gene were identified and related to luciferase reporter gene activity. Association of S100A14 expression with clinicopathologic features and survival in GC was analyzed.

RESULTS

We detected upregulated S100A2, S100A6, S100A10, and S100A11 expression and downregulated S100P and S100B expression in GC. Particularly, we detected differential mRNA and protein expression of S100A14 in GC cell lines and primary tumors. Furthermore, S100A14 expression change was related to a differentiated GC phenotype, with an expression in 31/40 (77.5 %) samples of well-differentiated tumors and 29/85 (34.1 %) samples of poorly differentiated tumors (P < 0.001). Moreover, 5-year survival was better in GC cases with positive than negative S100A14 level (P = 0.02). The genetic variant 425G>A on the 5'-UTR of S100A14 was associated with reduced S100A14 expression in GC cells.

CONCLUSION

Decreased expression of S100A14 with presence of its genetic variant 425G>A may be associated with an undifferentiated phenotype and poor prognosis in GC.

Effect of timing of metastasis/disease recurrence and histologic differentiation on survival of patients with advanced gastric cancer

BACKGROUND

Patients with advanced gastric cancer have a median survival (MS) of <9 months. It is unclear whether the MS of patients who have advanced cancer at the time of diagnosis (synchronous, Group A) is different from that for patients who develop advanced cancer after curative surgery (metachronous, Group B). It was hypothesized that survival would be similar.

METHODS

The medical records of all patients treated at the University of Texas M. D. Anderson Cancer Center who were in either Group A or Group B were reviewed. Survival of patients was assessed by the Kaplan-Meier method. A Cox proportional hazards model was used for multivariate hazards ratios that were adjusted for the effects of location of recurrence, histologic differentiation, patient sex and age, the location of the primary tumor, and timing of disease recurrence (Group A or Group B) on survival.

RESULTS

In all, 773 consecutive patients qualified for the analysis. The distribution of age, race, histologic differentiation, and primary tumor location was similar in both groups. The MS of Group A (n = 603 patients) and Group B (n = 170 patients) was the same (7.6 months). Similarly, the location of the primary tumor and patient sex were found to have no impact on survival. Patients with poorly differentiated tumors (World Health Organization grade 3 or 4) were found to have a shorter survival compared with those with well-differentiated or moderately differentiated tumors (grade 1 or 2; P = .004). Patients with distant metastases had a shorter survival (P = .01) than those with locoregional disease recurrence.

CONCLUSIONS

The data show that MS is similarly poor in patients with advanced gastric cancer with synchronous metastasis (Group A) or those with metachronous metastasis/disease recurrence (Group B). Poor differentiation and anatomically distant site of metastasis were found to impact MS adversely.

Prognostic factors for survival of patients with advanced gastric cancer treated with cisplatin-based chemotherapy

PURPOSE

The present study evaluated baseline patient- or tumor-related prognostic factors in patients with advanced gastric adenocarcinoma.

PATIENTS AND METHODS

A total of 304 consecutive patients with newly diagnosed metastatic or recurrent gastric cancer treated with one or more cycles of cisplatin-based chemotherapy at the Korea Cancer Center Hospital were enrolled in the current study.

RESULTS

Among the original 304 patients, only 4 patients were alive at the time of this analysis. The median survival for all patients was 7.3 (95% CI, 6.3-8.2) months. Five independent prognostic factors were identified by a multivariate analysis: poor performance status (hazard ratio [HR], 1.46; 95% CI, 1.32-2.92), elevated total bilirubin (HR, 2.04; 95% CI, 1.73-2.35), presence of peritoneal metastasis (HR, 1.73; 95% CI, 1.57-1.90), presence of bone metastasis (HR, 3.11; 95% CI, 2.69-3.53), and more than 1 metastatic site (HR, 1.22; 95% CI, 1.06-1.38). A prognostic index was constructed that divided the patients into a good (n = 162), moderate (n = 82), or poor (n = 60) risk group. The 1-year survival rates for the good, moderate, and poor risk groups were 34.6, 20.7, and 1.7%, respectively, and the survival differences among the groups were highly significant (P < 0.0001).

CONCLUSION

Five prognostic factors were identified from patients receiving first-line cisplatin-based chemotherapy for advanced gastric cancer. A simple prognostic index was then developed that produced distinct survival rates among the different risk groups. Therefore, this prognostic model could help clinicians and patients in clinical decision-making and treatment tailoring based on the estimated prognosis.

Surgical treatment and prognosis of gastric cancer in 2,613 patients

AIM

To analyze the factors influencing the prognosis of patients with gastric cancer after surgical treatment, in order to optimize the surgical procedures.

METHODS

A retrospective study of 2 613 consecutive patients with gastric cancer was performed. Of these patients, 2,301 (88.1%) received operations; 196 explorative laparotomy (EL), 130 by-pass procedure (BPP), and 1 975 surgical resection of the tumors (891 palliative resection and 1 084 curative resection). The survival rate was calculated by the actuarial life table method, and the prognostic factors were evaluated using the Cox regression proportional hazard model.

RESULTS

Of the patients, 2,450 (93.8%) were followed-up. The median survival period was 4.6 mo for patients without operation, 5.2 mo for EL, 6.4 mo for BPP, and 15.2 mo for palliative resection (P = 0.0001). Of the patients with surgical resection of the tumors, the overall 1, 3 and 5-year survival rates after were 82.7%, 46.3% and 31.1%, respectively, with the 5-year survival rate being 51.2% in patients with curative resection, and 7.8% for those with palliative resection. The 5-year survival rate was 32.5% for patients with total gastrectomy, and 28.3% for those with total gastrectomy plus resection of the adjacent organs. The factors that independently correlated with poor survival included advanced stage, upper third location, palliative resection, poor differentiation, type IV of Borrmann classification, tumor metastasis (N3), tumor invasion into the serosa and contiguous structure, proximal subtotal gastrectomy for upper third carcinoma and D1 lymphadenectomy after curative treatment.

CONCLUSION

The primary lesion should be resected as long as the local condition permitted for stage III and IV tumors, in order to prolong the patients' survival and improve their quality of life after operation. Total gastrectomy is indicated for carcinomas in the cardia and fundus, and gastric cancer involving the adjacent organs without distant metastasis requires gastrectomy with resection of the involved organs.

Multivariate prognostic factor analysis in locally advanced and metastatic esophago-gastric cancer--pooled analysis from three multicenter, randomized, controlled trials using individual patient data

PURPOSE

To identify baseline prognostic factors and assess whether pretreatment quality of life (QoL) predicts survival in patients with locally advanced or metastatic esophago-gastric cancer.

PATIENTS AND METHODS

Between 1992 and 2001, 1,080 patients were enrolled into three randomized, controlled trials assessing fluorouracil-based combination chemotherapy. All patients were required to complete the European Organization for Research and Treatment of Cancer core QoL questionnaire before random assignment.

RESULTS

Of the 1080 patients randomly assigned, 979 (91%) died. Four independent poor prognostic factors were identified by multivariate analysis: performance status >or= 2 (hazard ratio [HR], 1.58; 99% CI, 1.25 to 1.98), liver metastases (HR, 1.41; 99%CI, 1.14 to 1.74), peritoneal metastases (HR, 1.33; 99%CI, 1.01 to 1.74) and alkaline phosphatase >or= 100 U/L (HR, 1.41; 99% CI, 1.14 to 1.76). A prognostic index was constructed dividing patients into good (no risk factor), moderate (one or two risk factors) or poor (three or four risk factors) risk groups. One-year survival for good, moderate, and poor risk groups were 48.5%, 25.7%, and 11%, respectively, and the survival differences among these groups were highly significant (P <.00001). Compared with the good risk group, the moderate risk group had nearly twice the risk of death, and the poor risk group had 3.5-fold increased risk of death. Pretreatment physical (P =.003), role functioning (P <.001), and global QoL (P <.001) predicted survival.

CONCLUSION

Four poor prognostic factors were identified and a simple prognostic index was devised. Information from this analysis can be used to aid clinical decision-making, help individual patient risk stratification, and serve as benchmark for the planning for future phase III trials.

Leptomeningeal carcinomatosis originating from gastric cancer: report of eight cases and review of the literature

Leptomeningeal carcinomatosis caused by metastatic gastric adenocarcinoma has been rarely reported in the United States. We present eight cases of patients with gastric cancer who subsequently developed meningeal carcinomatosis. On average, patients presented with symptoms of leptomeningeal disease (LMD) 12 months after the initial diagnosis. Distinguishing features include a predominance of poorly differentiated histology, typically associated with signet ring cells, a diffuse pattern of primary organ involvement, systemic dissemination in the form of peritoneal carcinomatosis, and development of LMD despite responsiveness to chemotherapy elsewhere in the body. The natural history of these patients, with or without treatment, was uniformly poor. Although previously thought to be an extremely rare event, LMD in the setting of gastric adenocarcinoma may be a problem on the rise, possibly due to the increasing survival times of patients. Physicians should have a high index of suspicion since no single test can reliably diagnose this entity in all cases. Furthermore, the striking clinical picture of patients with LMD raises interesting questions about the biology and metastatic behavior of certain subclasses of gastric cancer.

c-Met expression in gastric cancer with liver metastasis

Liver metastasis is one of the poor prognostic factors for gastric cancer. Hepatocyte growth factor (HGF) and its receptor, c-Met, have been reported to be related to the proliferation of carcinoma cells. We examined c-Met and HGF expression in stage IV gastric cancers (n = 121) and compared the results in groups with liver metastasis (n = 47, LM group) and without liver metastasis (n = 74, no-LM group). The survival rate for the LM group was significantly poorer than for the no-LM group (p < 0.01). We found a high frequency of c-Met expression in the LM group compared with the no-LM group at protein level detected by immunohistochemistry (p = 0.0005) and at mRNA level detected by semiquantitative reverse transcriptase-polymerase chain reaction (p = 0.0386) in primary gastric tumors. Furthermore, we evaluated HGF expression in both carcinoma cells and stromal cells in gastric cancers. There was no significant difference in the HGF expression between the LM and no-LM groups. The labeling index of proliferating cell nuclear antigen for the carcinomas in the LM group was higher than that in the no-LM group (47.1 +/- 24.5 vs. 26.2 +/- 24.5%, p < 0.0001). Thus, the high frequency of c-Met overexpression in carcinoma cells may be involved in the mechanism of liver metastasis in gastric cancers. Moreover, the evaluation of c-Met expression might be a useful indicator of liver metastasis in patients with gastric cancer.

Treatment of advanced gastric cancer with etoposide, folinic acid, and fluorouracil in the clinical setting: efficacy of therapy and value of serum tumor markers

The combination of etoposide, folinic acid, and 5-fluorouracil (5-FU) (ELF regimen) has been proved to be an active chemotherapy in patients with advanced gastric cancer. The aim of this study was to confirm the efficacy in the clinical setting and to correlate response with different parameters like serum tumor markers. We treated 60 patients with advanced gastric cancer with 120 mg/m2 etoposide, 300 mg/m2 folinic acid, and 500 mg/m2 5-FU, on d 1-3. The cycle was repeated on d 21. Objective response was obtained in 23% of all patients with measurable disease. Stable disease was obtained in 37%. The tumor-growth-control rate in patients with proximal carcinoma was significantly higher than in those with distal carcinoma (85% vs 48%, p = 0.04). Median survival for all patients was 8.0 mo (95% confidence interval [CI] 7.0-8.5). In responsive patients, survival was more than two-fold longer than in patients with progressive disease. The administration of ELF could be performed safely on an outpatient basis. Toxicity was rather mild. The most frequently elevated serum tumor marker was CA 72-4 (55% of the patients). An elevated level of carcinoembryonic antigen before treatment was significantly correlated with progressive disease. A more than two-fold elevation of at least one marker under treatment was significantly correlated to progressive disease (p < 0.002). A reduction of at least one marker under treatment was significantly correlated to tumor growth control (p < 0.00015). The results of the present trial confirm the efficacy and low toxicity of the ELF regimen in advanced gastric carcinoma. Serum tumor markers proved suitable parameters for assessing response to treatment.

[Survival and prognostic factors for gastric cancer. Analysis of 2,334 patients]

BACKGROUND

The analysis of the survival of patients diagnosed with gastricadenocarcinoma and the factors which modify prognosis.

PATIENTS AND METHOD

Retrospective cohort study of overall patients diagnosed with gastric adenocarcinoma treated in the Xeral-Calde and Juan Canelejo hospitals of Lugo and La Coruña (Spain) between 1975 and 1993. The following variables were studied: age, sex, the year of diagnosis, place of residence, delayed diagnosis, localisation of the primitive tumour, the TNM classification, the Laurén histological type and the type of surgical resection when conducted. The Kaplan-Meier statistical method was employed to determine the probability of survival. Cox regression was used to determine prognosis factors.

RESULTS

The diagnosis was established on 2,334 patients: 63,2% were males;the average overall age was 66.5 (11,9 SD) years, the median delayed diagnostic was 3,19 months, the lower third was the most common localisation (46,3%), 30,2% of the cases were diagnosed in the IV stage, and curative surgery was conducted in 46,4% of the cases. The probability of survival for overall numbers was 26% and curative surgery, was conducted in 45% of cases. The most advanced states in the TNM classification and the absence of curative surgery were factors associated with the poorest prognosis.

CONCLUSIONS

Survival after gastric cancer is low. Initial stage and radical surgical treatment are the main factors for prognosis.