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Bhandare MS, Gundavda KK, Yelamanchi R, Chopde A, Batra S, Kolhe M, Ramaswamy A, Ostwal V, Deodhar K, Chaudhari V, Shrikhande SV. Impact of pCR after neoadjuvant chemotherapy and radical D2 dissection in locally advanced gastric cancers: Analysis of 1001 cases. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108343. [PMID: 38640606 DOI: 10.1016/j.ejso.2024.108343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 04/09/2024] [Accepted: 04/12/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND Advances in perioperative chemotherapy have improved outcomes in patients with gastric cancers (GC). This strategy leads to tumour downstaging and may result in a pathologic complete response (pCR). The study aimed to evaluate the predictors of pCR and determine the impact of pCR on long-term survival. METHODS At the Department of Gastrointestinal and HPB Oncology at the Tata Memorial Centre, Mumbai, 1001 consecutive patients with locally advanced GCs undergoing radical resection following neoadjuvant chemotherapy from January 2005 to June 2022 were included. RESULTS At a median follow-up of 61 months, the median OS was 53 months with a 5-year OS of 46.8 %. Ninety-five patients (9.49 %) realized pCR. Non-signet and well-differentiated histology were associated with pCR. pCR was significantly associated with improved OS, 5-year OS 79.2 % vs 43.2 % (HR 0.30, p < 0.001). On multivariable analysis, the realization of pCR and completion of adjuvant chemotherapy had superior OS. Whereas, signet-ring histology, linitis-like tumours, and high lymph node ratio had adverse outcomes. CONCLUSION Tumour grade and signet-ring histology predict achievement of pCR in locally advanced GCs after neoadjuvant chemotherapy. Patients with pCR have significantly improved survival. Future neoadjuvant strategies should focus on enhancing pCR rates to improve overall outcomes.
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Affiliation(s)
- Manish S Bhandare
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
| | - Kaival K Gundavda
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
| | - Raghav Yelamanchi
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
| | - Amit Chopde
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
| | - Swati Batra
- Department of Surgical Oncology, Armed Forces Medical Services (Army Hospital, Research and Referral), Delhi, India.
| | - Manjushree Kolhe
- Department of Statistics, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
| | - Anant Ramaswamy
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
| | - Vikas Ostwal
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
| | - Kedar Deodhar
- Department of Pathology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
| | - Vikram Chaudhari
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
| | - Shailesh V Shrikhande
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
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Marano L, Carbone L, Poto GE, Restaino V, Piccioni SA, Verre L, Roviello F, Marrelli D. Extended Lymphadenectomy for Gastric Cancer in the Neoadjuvant Era: Current Status, Clinical Implications and Contentious Issues. Curr Oncol 2023; 30:875-896. [PMID: 36661716 PMCID: PMC9858164 DOI: 10.3390/curroncol30010067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 01/11/2023] Open
Abstract
Despite its decreasing incidence, gastric cancer remains an important global healthcare problem due to its overall high prevalence and high mortality rate. Since the MAGIC and FNLCC/FFCD trials, the neoadjuvant chemotherapy has been recommended throughout Europe in gastric cancer. Potential benefits of preoperative treatments include a higher rate of R0 resection achieved by downstaging the primary tumor, a likely effect on micrometastases and isolated tumor cells in the lymph nodes, and, as a result, improved cancer-related survival. Nevertheless, distortion of anatomical planes of dissection, interstitial fibrosis, and sclerotic tissue changes may increase surgical difficulty. The collection of at least twenty-five lymph nodes after neoadjuvant therapy would seem to ensure removal of undetectable node metastasis and reduce the likelihood of locoregional recurrence. It is not what you take but what you leave behind that defines survival. Therefore, para-aortic lymph node dissection is safe and effective after neoadjuvant chemotherapy, in both therapeutic and prophylactic settings. In this review, the efficacy of adequate lymph node dissection, also in a neoadjuvant setting, has been investigated in the key studies conducted to date on the topic.
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Affiliation(s)
| | - Ludovico Carbone
- Unit of Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, 53100 Siena, Italy
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Singh HK, Chaudhari V, Batra S, Ostwal V, Ramaswamy A, Mokal S, Shrikhande SV, Bhandare MS. Radical D2 gastrectomy with adjuvant chemotherapy for stage IB/II/III distal gastric cancers in the era of perioperative chemotherapy: A propensity matched comparison. Am J Surg 2021; 223:1055-1062. [PMID: 34756584 DOI: 10.1016/j.amjsurg.2021.10.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 10/06/2021] [Accepted: 10/22/2021] [Indexed: 01/26/2023]
Abstract
AIM This study aimed to assess the impact of treatment sequencing on long-term survival, in distal gastric cancers (GCs) (stage IB/II/III). METHODS This retrospective study included patients with distal GC undergoing D2 resection. Outcomes were compared between group 1 (surgery with adjuvant chemotherapy) and group 2 (perioperative chemotherapy with surgery). 1:1 matching for baseline characteristics (age, cT, and cN stage) was performed for outcome comparison. RESULTS At a median follow-up of 47.5 months in the included 342 patients, the 5-year overall survival (OS) was 61.1% and disease-free survival (DFS) was 50.5%. OS was comparable in the unmatched (group 1, n = 118; group 2, n = 224) (HR 0.905, 95%CI 0.64-1.33, P = 0.615) and matched groups (group 1, n = 97; group 2, n = 97) (HR 0.77, 95% CI 0.48-1.26, P = 0.3). CONCLUSION D2 resection followed by adjuvant chemotherapy provides similar long-term outcomes as compared to perioperative chemotherapy approach for stage IB/II/III distal GCs.
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Affiliation(s)
- Hemant Kumar Singh
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, 400012, Maharashtra, India; Department of Surgical Oncology, All India Institute of Medical Sciences, Mangalagiri, Guntur, 522503, India
| | - Vikram Chaudhari
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, 400012, Maharashtra, India
| | - Swati Batra
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, 400012, Maharashtra, India
| | - Vikas Ostwal
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, 400012, Maharashtra, India
| | - Anant Ramaswamy
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, 400012, Maharashtra, India
| | - Smruti Mokal
- Clinical Research Secretariat, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, 400012, Maharashtra, India
| | - Shailesh V Shrikhande
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, 400012, Maharashtra, India
| | - Manish S Bhandare
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, 400012, Maharashtra, India.
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4
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Pachaury A, Chaudhari V, Batra S, Ramaswamy A, Ostwal V, Engineer R, Bal M, Shrikhande SV, Bhandare MS. Pathological N3 Stage (pN3/ypN3) Gastric Cancer: Outcomes, Prognostic Factors and Pattern of Recurrences After Curative Treatment. Ann Surg Oncol 2021; 29:229-239. [PMID: 34283313 DOI: 10.1245/s10434-021-10405-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/21/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND pN3 or ypN3 stage gastric cancers (GCs) are known to have aggressive clinical behaviour. This study aimed to investigate factors affecting survival and pattern of recurrences of N3 stage GCs, treated with curative intent. METHODS A total of 196 GC patients, operated on at the Tata Memorial Centre from 2003 to 2017 and reported as pN3 or ypN3 status on histopathology after D2 gastrectomy were included in this retrospective analysis. RESULTS On multivariate analysis, use of NACT (neoadjuvant chemotherapy) and LN ratio (≤ 0.5/> 0.5) emerged as significant predictors for long-term survival. Patients who received NACT but were still harbouring N3 nodes (ypN3; n = 102) had a worse prognosis than those operated on upfront (pN3; n = 94), with a median survival of 19 months versus 24 months respectively (p = 0.003). The 5-year overall survival of the entire cohort was 16.3% (95% CI 12.8-19.8%), while 5-year disease-free survival (DFS) was 14.6% (95% CI 12.6-20%). Adjuvant chemoradiotherapy, though offered in a small number of patients (n = 38) resulted in improvement in DFS. Median DFS of adjuvant CT versus adjuvant CRT was 13 months versus 23 months (p = 0.020). The commonest site of relapse was the peritoneum (49.18%) and incidence of isolated loco-regional failure was 10.7%. CONCLUSION In GCs with N3 stage determined after radical D2 gastrectomy, LN ratio of > 0.5 and ypN3 status are predictors of poor prognosis. Considering the high incidence of peritoneal and loco-regional relapse in these patients, the role of more radical surgery, adjuvant chemoradiotherapy after upfront resection and intraperitoneal chemotherapy should be evaluated in prospective randomized clinical trials.
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Affiliation(s)
- Anadi Pachaury
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Vikram Chaudhari
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Swati Batra
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Anant Ramaswamy
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Vikas Ostwal
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Reena Engineer
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Munita Bal
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Pathology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Shailesh V Shrikhande
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Manish S Bhandare
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
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Lin JX, Xu YC, Lin W, Xue FQ, Ye JX, Zang WD, Cai LS, You J, Xu JH, Cai JC, Tang YH, Xie JW, Li P, Zheng CH, Huang CM. Effectiveness and Safety of Apatinib Plus Chemotherapy as Neoadjuvant Treatment for Locally Advanced Gastric Cancer: A Nonrandomized Controlled Trial. JAMA Netw Open 2021; 4:e2116240. [PMID: 34241629 PMCID: PMC8271357 DOI: 10.1001/jamanetworkopen.2021.16240] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 05/03/2021] [Indexed: 02/03/2023] Open
Abstract
Importance Apatinib is a novel treatment option for chemotherapy-refractory advanced gastric cancer (GC), but it has not been evaluated in patients with locally advanced GC. Objective To investigate the effectiveness and safety of apatinib combined with S-1 plus oxaliplatin (SOX) as a neoadjuvant treatment for locally advanced GC. Design, Setting, and Participants This multicenter, prospective, single-group, open-label, phase 2 nonrandomized controlled trial was conducted in 10 centers in southern China. Patients with M0 and either clinical T2 to T4 or N+ disease were enrolled between July 1, 2017, and June 30, 2019. Statistical analysis was performed from December 1, 2019, to January 31, 2020. Interventions Eligible patients received apatinib (500 mg orally once daily on days 1 to 21 and discontinued in the last cycle) plus SOX (S-1: 40-60 mg orally twice daily on days 1 to 14; oxaliplatin: 130 mg/m2 intravenously on day 1) every 3 weeks for 2 to 5 cycles. A D2 gastrectomy was performed 2 to 4 weeks after the last cycle. Main Outcomes and Measures The primary end point was R0 resection rate. Secondary end points were the response rate, toxic effects, and surgical outcome. Results A total of 48 patients (mean [SD] age, 63.2 [8.2] years; 37 men [77.1%]) were enrolled in this study. Forty patients underwent surgery (38 had gastrectomy, and 2 had exploratory laparotomy), with an R0 resection rate of 75.0% (95% CI, 60.4%-86.4%). The radiologic response rate was 75.0%, and T downstaging was observed in 16 of 44 patients (36.4%). The pathological response rate was 54.2% (95% CI, 39.2%-68.6%); moreover, this rate was significantly higher in patients who achieved a radiologic response compared with those who did not (12 [80.0%] vs 1 [20.0%]; P = .03) and in those who had an Eastern Cooperative Oncology Group Performance Status score of 0 (20 [76.9%] vs 10 [45.5%]; P = .03) or had tumors located in the upper one-third of the stomach (16 [61.5%] vs 7 [31.8%]; P = .04). Patients who achieved a pathological response (vs those who did not) had significantly less blood loss (median [range]: 60 [10-200] mL vs 80 [20-300] mL; P = .04) and significantly more lymph nodes harvested (median [range]: 40 [24-67] vs 32 [19-51]; P = .04) during surgery. Postoperative complications were observed in 7 of 38 patients (18.4%). Grade 3 toxic effects occurred in 16 of 48 patients (33.3%), and no grade 4 toxic effects or preoperative deaths were observed. Conclusions and Relevance This nonrandomized controlled trial found that apatinib combined with SOX was effective and had an acceptable safety profile as a neoadjuvant treatment for locally advanced GC. A large-scale randomized clinical trial may be needed to confirm the findings. Trial Registration ClinicalTrials.gov Identifier: NCT03192735.
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Affiliation(s)
- Jian-Xian Lin
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China
| | - Yan-Chang Xu
- Department of Gastrointestinal Surgery, The First Hospital of Putian, Putian, Fujian Province, China
| | - Wei Lin
- Department of Gastrointestinal Surgery and Gastrointestinal Surgery Research Institute, The Affiliated Hospital of Putian University, Putian, Fujian Province, China
| | - Fang-Qin Xue
- Department of Gastrointestinal Surgery, Fujian Provincial Hospital, Fuzhou, Fujian Province, China
| | - Jian-Xin Ye
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian Province, China
| | - Wei-Dong Zang
- Department of Gastrointestinal Surgery, Fujian Provincial Cancer Hospital, Fuzhou, Fujian Province, China
| | - Li-Sheng Cai
- Department of General Surgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, Fujian Province, China
| | - Jun You
- Department of Gastrointestinal Oncology Surgery, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian Province, China
| | - Jian-Hua Xu
- Department of Oncology Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, China
| | - Jian-Chun Cai
- Department of Gastrointestinal Surgery, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, Fujian Province, China
| | - Yi-Hui Tang
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Jian-Wei Xie
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China
| | - Ping Li
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China
| | - Chao-Hui Zheng
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China
| | - Chang-Ming Huang
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China
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Kazi M, Shrikhande SV, Chaudhari VA, Kurunkar S, Bhandare MS. Emergency Radical Gastrectomy with Pancreatico-duodenectomy for a Recent Onset Perforation of Locally Advanced Gastric Cancer with Pancreatic Head Involvement-Exceptional but a Definite Option. Indian J Surg Oncol 2020; 11:278-281. [PMID: 33364719 DOI: 10.1007/s13193-020-01189-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 08/19/2020] [Indexed: 11/26/2022] Open
Abstract
Gastric cancer perforations are rare events with management options ranging from lavage and perforation closure, to resection. Usual aim is to perform a damage control procedure, and very few patients are suitable for a curative resection. We report the first case of emergency gastrectomy with pancreatico-duodenectomy performed in emergency for a perforated stomach cancer with pancreatic head invasion. The patient was a 32-year-old gentleman who presented with a perforated antro-pyloric cancer with infiltration of pancreatic head. Emergency radical gastrectomy with en-bloc pancreatico-duodenectomy was performed with due considerations to the patient and disease factors. He had an uneventful postoperative recovery and remains disease free at 18 months of follow-up after having received adjuvant chemotherapy. Curative resections should be selectively offered in advanced (T4b) gastric cancers in patients without multiple adverse factors. In an emergency situation with perforation peritonitis, if the magnitude of resection is deemed unlikely to add to significant morbidity of the surgery, taking multiple factors into consideration, an R0 resection can offer a large survival benefit in such settings.
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Affiliation(s)
- Mufaddal Kazi
- Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | | | - Vikram A Chaudhari
- Department Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra 400012 India
| | - Sagar Kurunkar
- Apple Saraswati Multi-specialty Hospital, Kolhapur, India
| | - Manish S Bhandare
- Department Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra 400012 India
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7
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Rausei S, Bali CD, Lianos GD. Neoadjuvant chemotherapy for gastric cancer. Has the time to decelerate the enthusiasm passed us by? Semin Oncol 2020; 47:355-360. [PMID: 32758372 DOI: 10.1053/j.seminoncol.2020.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 07/08/2020] [Accepted: 07/08/2020] [Indexed: 11/11/2022]
Abstract
Neoadjuvant therapy for locally advanced gastric cancer is a treatment option well recognized in international guidelines. However, neither completed randomized trials nor ongoing studies (will) offer definitive answers about the efficacy of neoadjuvant therapy. With extensive experience confirming the safety and some efficacy for this approach most current studies are focused on identifying the best preoperative treatment regimen. We try to clarify if is really the time to slow down the enthusiasm about neoadjuvant approach.
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Affiliation(s)
- Stefano Rausei
- Department of Surgery, ASST Valle Olona, Gallarate Varese, Italy..
| | - Christina D Bali
- Department of Surgery, University Hospital of Ioannina & University of Ioannina, Ioannina, Greece
| | - Georgios D Lianos
- Department of Surgery, University Hospital of Ioannina & University of Ioannina, Ioannina, Greece
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8
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Purkayastha J, Yadav J, Talukdar A, Das G, Pegu N, Madhav S, Singh PR, Mamidala V. Radical Gastrectomy: Still the Gold Standard Treatment for Gastric Cancer-Our Experience from a Tertiary Care Center from Northeast India. Indian J Surg Oncol 2020; 11:66-70. [PMID: 32205973 DOI: 10.1007/s13193-019-00990-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 09/25/2019] [Indexed: 10/25/2022] Open
Abstract
Gastric cancer (GC) is common in the northeast and southern parts of India. Radical surgery is the cornerstone of treatment and offers the only chance for cure. This study was conducted to assess the outcomes of all resectable gastric cancers that presented to our tertiary cancer center in Northeast India. All patients undergoing upfront surgery for gastric cancer with curative intention between 2012 and 2017 were included in the study. A total of 116 patients who underwent upfront radical gastrectomy were included in the study. Males (58.6%) were more common than females (41.4%). Mean age at presentation was 56.12 years (range 26-89). The most common mode of presentation was pain abdomen (53.8%). The most common location of tumor was the distal part (81%) followed by the proximal part (10.3%). The most commonly done procedure was distal radical gastrectomy (56.9%) followed by subtotal gastrectomy (32.8%). Median number of lymph nodes isolated was 14. Fifty-four patients received adjuvant chemotherapy while 32 patients received adjuvant chemoradiation (CTRT). At a median follow-up of 14 months (range, 2-78 months), overall 5-year survival was 23.75% (mean survival 33.77 months, median survival 24 months). The 5-year survival for stages I-III was 100%, 26.25%, and 11.25%, respectively (P < 0.001). Though perioperative chemotherapy has a role in gastric cancer, it is not the substitute for radical D2 gastrectomy which is still the gold standard treatment especially in high-volume centers.
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Affiliation(s)
- Joydeep Purkayastha
- 1Department of Surgical Oncology, Dr. B. Borooah Cancer Institute, Gopinath Nagar, Guwahati, 781016 India
| | - Jitin Yadav
- 1Department of Surgical Oncology, Dr. B. Borooah Cancer Institute, Gopinath Nagar, Guwahati, 781016 India
| | - Abhijit Talukdar
- 1Department of Surgical Oncology, Dr. B. Borooah Cancer Institute, Gopinath Nagar, Guwahati, 781016 India
| | - Gaurav Das
- 1Department of Surgical Oncology, Dr. B. Borooah Cancer Institute, Gopinath Nagar, Guwahati, 781016 India
| | - Niju Pegu
- 1Department of Surgical Oncology, Dr. B. Borooah Cancer Institute, Gopinath Nagar, Guwahati, 781016 India
| | - Srishti Madhav
- Department of Prosthodontics, Dental College, Azamgarh, India
| | - Pritesh R Singh
- 1Department of Surgical Oncology, Dr. B. Borooah Cancer Institute, Gopinath Nagar, Guwahati, 781016 India
| | - Vinay Mamidala
- 1Department of Surgical Oncology, Dr. B. Borooah Cancer Institute, Gopinath Nagar, Guwahati, 781016 India
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9
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Pardo F, Osorio J, Miranda C, Castro S, Miró M, Luna A, Garsot E, Momblán D, Galofré G, Rodríguez-Santiago J, Pera M. A real-life analysis on the indications and prognostic relevance of perioperative chemotherapy in locally advanced resectable gastric adenocarcinoma. Clin Transl Oncol 2019; 22:1335-1344. [PMID: 31865605 DOI: 10.1007/s12094-019-02261-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 12/05/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Perioperative chemotherapy (periCTX) based on the "MAGIC" scheme has become a standard treatment in Europe for locally advanced oesophagogastric cancer. We assessed implementation and long-term oncological outcomes of MAGIC periCTX for locally advanced gastric cancer. METHODS Population-based cohort study of all patients with locally advanced gastric cancer undergoing surgical resection with curative intent in Catalonia and Navarra (the first two autonomous communities included in the EURECCA Upper GI Spanish Working Group) between January 2011 and December 2013. The main variable was the percentage of patients treated with MAGIC periCTX. Kaplan-Meier analysis and Cox proportional hazards model were used to assess the survival benefit of periCTX. RESULTS Among 814 patients, 217 (26.6%) received periCTX (especially patients more likely to receive it: aged < 70 years, with proximal tumors, low anesthetic risk, and cT3-4/cN+ clinical stage). 35% did not complete perioperative chemotherapy, with no relationship with age. PeriCTX showed no effect on postoperative morbimortality. Histological tumor regression was more often absent or poor (38.2%) than total or almost total (27.8%), although clinico-pathological lymph-node downstaging was higher than expected by staging inaccuracy (38.7% vs. 24.2%). PeriCTX was associated with a better survival only in cT3-4 and cN+ patients, showing less prognostic relevance than optimal oncological surgery with D2 lymphadenectomy. CONCLUSIONS Only 26.6% of locally advanced resectable gastric cancer patients received PeriCTX. Pathological response was poor, although some degree of nodal downstaging was observed. Survival benefit of periCTX was limited to cT3-4 and cN+ patients, being less relevant than D2 lymphadenectomy.
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Affiliation(s)
- F Pardo
- Service of Digestive Surgery, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Carretera de Canyet, s/n, 08916, Badalona, Barcelona, Spain.
| | - J Osorio
- Service of General and Digestive Surgery, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain
| | - C Miranda
- Esophagogastric Surgery Unit, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - S Castro
- Department of General Surgery, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - M Miró
- Service of General and Digestive Surgery, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - A Luna
- Department of General Surgery, Consorci Corporació Sanitària Parc Taulí, Sabadell, Barcelona, Spain
| | - E Garsot
- Service of Digestive Surgery, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Carretera de Canyet, s/n, 08916, Badalona, Barcelona, Spain
| | - D Momblán
- Service of Gastrointestinal Surgery, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - G Galofré
- Department of Surgery, Hospital de Sant Joan Despí Moisés Broggi, Sant Joan Despí, Barcelona, Spain
| | - J Rodríguez-Santiago
- Service of General and Digestive Surgery, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain
| | - M Pera
- Section of Gatrointestinal Surgery, Hospital Universitari del Mar, IMIM (Hospital del Mar Medical Research Institute), Universitat Autònoma de Barcelona, Barcelona, Spain
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Radical Gastrectomy: Still the Cornerstone of Curative Treatment for Gastric Cancer in the Perioperative Chemotherapy Era-A Single Institute Experience over a Decade. Int J Surg Oncol 2018; 2018:9371492. [PMID: 29568650 PMCID: PMC5820646 DOI: 10.1155/2018/9371492] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 11/27/2017] [Indexed: 12/26/2022] Open
Abstract
Background and Objectives Most gastric cancer patients now undergo perioperative chemotherapy (POCT) based on the MAGIC trial results. POCT consists of neoadjuvant chemotherapy (NACT) as well as postoperative adjuvant chemotherapy. This study assessed the applicability of perioperative chemotherapy and the impact of radical gastrectomy encompassing a detailed lymph-node resection on outcomes of gastric cancer. Methods Medical and pathology records of all gastric carcinoma resections were reviewed from 2006 onwards. Pathological details, number of lymph-nodes resected, and proportion of involved nodes, reasons for nonadministration of NACT, complications, recurrence, and survival data were analysed. Results Only twenty-eight (37.8%) out of 74 patients underwent NACT and only nine completed POCT. NACT was declined due to comorbidities/patient refusal n = 24, early stage n = 14, and emergency presentation n = 8. Patients receiving NACT were much younger. Anastomotic leaks, hospital-mortality, lymph-node yield, and proportion of involved lymph-nodes were similar in both groups. Thirty-two patients died due to recurrence with lymph-node involvement heralding higher recurrence risk and much poorer survival (HR 2.66; p = 0.013). Conclusion More than 60% patients with resectable gastric carcinoma did not undergo NACT. Radical gastrectomy with lymphadenectomy remained the cornerstone of treatment in this period.
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Barreto SG, Sirohi B. Why should we perform a D2 lymphadenectomy in gastric cancer? Future Oncol 2017; 13:2009-2012. [PMID: 28984466 DOI: 10.2217/fon-2017-0282] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Savio George Barreto
- Hepatobiliary & Oesophagogastric Unit, Division of Surgery & Perioperative Medicine Flinders Medical Centre, Bedford Park, Adelaide, South Australia - Australia.,School of Medicine, Faculty of Medicine, Nursing & Health Sciences, Flinders University, South Australia - Australia
| | - Bhawna Sirohi
- Department of Medical Oncology, Barts Cancer Institute, Queen Mary University of London, London, UK
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12
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Ghadyalpatil NS, Supriya C, Prachi P, Ashwin D, Avanish S. Gastrointestinal cancers in India: Treatment perspective. South Asian J Cancer 2016; 5:126-36. [PMID: 27606298 PMCID: PMC4991133 DOI: 10.4103/2278-330x.187585] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
GI cancer is not one cancer but is a term for the group of cancers that affect the digestive system including gastric cancer (GC), colorectal cancer (CRC), hepatocellular carcinoma (HCC), esophageal cancer (EC), and pancreatic cancer (PC). Overall, the GI cancers are responsible for more cancers and more deaths from cancer than any other organ. 5 year survival of these cancers remains low compared to western world. Unlike the rest of the world where organ based specialities hepatobiliary, pancreatic, colorectal and esophagogastric exist, these cancers are managed in India by either a gastrointestinal surgeons, surgical oncologist, or a general surgeon with varying outcomes. The aim of this review was to collate data on GI cancers in indian continent. In colorectal cancers, data from tertiary care centres identifies the unique problem of mucinous and signet colorectal cancer. Results of rectal cancer resection in terms of technique (intersphincteric resection, extralevator aper, minimal invasive approach) to be comparable with world literature. However long term outcome and data regarding colon cancers and nationally is needed. Gastric cancer at presentation are advanced and in surgically resected patients, there is need for a trial to compare chemoradiation vs chemotherapy alone to prevent loco regional recurrence. Data on minimal invasive gastric cancer surgery may be sparse for the same reason. Theree is a lot of data on surgical techniques and perioperatve outcomes in pancreatic cancer. There is a high volume of locally advanced gallbladder cancers with efforts on to decide whether neoadjuvant chemotherapy or neoadjuvant chemoradiotherapy is better for down staging. Considering GI cancers, a heterogeneous disease with site specific treatment options and variable outcomes, the overall data and outcomes are extremely variable. Young patients with pathology unique to the Indian subcontinent (for example, signet ring rectal cancer, GBCs) need focussed attention. Solution for such pathology needs to come from the Indian continent itself. Joint efforts to improve outcomes for GI cancer can be integrated under the national cancer grid program.
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Affiliation(s)
| | - Chopra Supriya
- Department of Radiation Oncology, Tata Memorial Center, Mumbai, Maharashtra, India
| | - Patil Prachi
- Department of Gastroenterology, Tata Memorial Center, Mumbai, Maharashtra, India
| | - Dsouza Ashwin
- Department of GI Surgical Oncology, Tata Memorial Center, Mumbai, Maharashtra, India
| | - Saklani Avanish
- Department of GI Surgical Oncology, Tata Memorial Center, Mumbai, Maharashtra, India
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Khan SA, Amnekar R, Khade B, Barreto SG, Ramadwar M, Shrikhande SV, Gupta S. p38-MAPK/MSK1-mediated overexpression of histone H3 serine 10 phosphorylation defines distance-dependent prognostic value of negative resection margin in gastric cancer. Clin Epigenetics 2016; 8:88. [PMID: 27588146 PMCID: PMC5007744 DOI: 10.1186/s13148-016-0255-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 08/21/2016] [Indexed: 01/09/2023] Open
Abstract
Background Alterations in histone modifications are now well known to result in epigenetic heterogeneity in tumor tissues; however, their prognostic value and association with resection margins still remain poorly understood and controversial. Further, histopathologically negative resection margins in several cancers have been associated with better prognosis of the disease. However, in gastric cancer, despite a high rate of R0 resection, a considerably high incidence of loco-regional recurrence is observed. We believe alterations of global histone post-translational modifications could help in identifying molecular signatures for defining the true negative surgical resection margins and also the prognosis of gastric cancer patients. Results The present study compares the level of H3S10ph among paired tumor and histopathologically confirmed disease-free (R0) proximal and distal surgical resection margin (PRM and DRM) tissue samples of GC patients (n = 101). Immunoblotting and immune-histochemical analysis showed a significantly (p < 0.01) higher level of H3S10ph in tumor compared to R0 surgical resection margins. Along with tumor, high H3S10ph levels in both PRM and DRM correlated with clinical parameters and poor survival. Interestingly, in the case of PRM and DRM, the association of H3S10ph with poor survival was only found in a patient group with the resection margin distance <4 cm. Further investigations revealed that the increase of H3S10ph in tumor tissues is not due to the change in cell cycle profile but rather an interphase-associated phenomenon. Moreover, an increase in ph-MSK1 and ph-p38 levels in tumor tissues and the decrease in ph-MSK1 and H3S10ph on p38 inhibition in gastric cancer cells confirmed p38-MAPK/MSK1 pathway-mediated regulation of H3S10ph in gastric cancer. Conclusions Our study provides the first evidence that p38-MAPK/MSK1-regulated increase of H3S10ph in GC is predictive of a more aggressive cancer phenotype and could help in defining true negative surgical resection margin. Importantly, our data also gave a new rationale for exploration of the use of MSK1 inhibitor in gastric cancer therapy and the combination of histone post-translational modifications, H4K16ac and H4K20me3 along with H3S10ph as epigenetic prognostic markers. Electronic supplementary material The online version of this article (doi:10.1186/s13148-016-0255-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Shafqat Ali Khan
- Epigenetics and Chromatin Biology Group, Gupta Laboratory, Cancer Research Centre, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Kharghar, Navi Mumbai, MH 410210 India ; Homi Bhabha National Institute, Training School Complex, Anushakti Nagar, Mumbai, MH 400085 India
| | - Ramchandra Amnekar
- Epigenetics and Chromatin Biology Group, Gupta Laboratory, Cancer Research Centre, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Kharghar, Navi Mumbai, MH 410210 India ; Homi Bhabha National Institute, Training School Complex, Anushakti Nagar, Mumbai, MH 400085 India
| | - Bharat Khade
- Epigenetics and Chromatin Biology Group, Gupta Laboratory, Cancer Research Centre, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Kharghar, Navi Mumbai, MH 410210 India
| | | | - Mukta Ramadwar
- Department of Pathology, Tata Memorial Hospital, Mumbai, MH 400012 India
| | - Shailesh V Shrikhande
- Department of Surgical Oncology, Gastrointestinal and Hepato-Pancreato-Biliary Service, Tata Memorial Hospital, Mumbai, MH 400012 India
| | - Sanjay Gupta
- Epigenetics and Chromatin Biology Group, Gupta Laboratory, Cancer Research Centre, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Kharghar, Navi Mumbai, MH 410210 India ; Homi Bhabha National Institute, Training School Complex, Anushakti Nagar, Mumbai, MH 400085 India
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Wang X, Zhao L, Liu H, Zhong D, Liu W, Shan G, Dong F, Gao W, Bai C, Li X. A phase II study of a modified FOLFOX6 regimen as neoadjuvant chemotherapy for locally advanced gastric cancer. Br J Cancer 2016; 114:1326-33. [PMID: 27172250 PMCID: PMC4984457 DOI: 10.1038/bjc.2016.126] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 03/11/2016] [Accepted: 04/18/2016] [Indexed: 02/07/2023] Open
Abstract
Background: We evaluated the efficacy and safety of the modified FOLFOX6 (mFOLFOX6) regimen as
a neoadjuvant chemotherapy in gastric cancer patients. Methods: Seventy-three patients with T2–T4 or N+ were enroled. Preoperative
chemotherapy consisted of three cycles of mFOLFOX6. The primary end points were
the response rate and the R0 resection rate. Prognostic factors for overall
survival (OS) were investigated using univariate and multivariate analyses. Results: Sixty-seven (91.8%) patients completed 3 cycles, with grade 3–4
toxicity arising in 33.0%. The radiology response rate was 45.8%.
Sixty-seven (91.8%) patients receiving radical surgery showed different
levels of histological regression of the primary tumour, with a ⩾50%
regression rate of 49.2%. ypTNM stage (HR 4.045, 95% CI
1.429–11.446) and tumours of diffuse and mixed type (HR 9.963, 95% CI
1.937–51.235; HR 8.890, 95% CI 1.157–68.323, respectively) were
significantly associated with OS. The pathologic regression rate (GHR;
⩾2/3/<2/3, ⩾50%/<50%) was
statistically significantly associated with OS according to a univariate
analysis. Conclusions: Perioperative mFOLFOX6 was a tolerable and effective regimen for gastric cancer.
The ypTNM stage was an independent predictor of survival. GHR
⩾50%/<50% could be used as a surrogate marker for
selecting a postoperative chemotherapy regimen.
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Affiliation(s)
- Xiang Wang
- Department of Medical Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100032, China
| | - Lin Zhao
- Department of Medical Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100032, China
| | - Hongfeng Liu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Dingrong Zhong
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Wei Liu
- Department of Radiation, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Guangliang Shan
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of basic Medicine, Peking Union Medical College, Beijing 100005, China
| | - Fen Dong
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of basic Medicine, Peking Union Medical College, Beijing 100005, China
| | - Weisheng Gao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Chunmei Bai
- Department of Medical Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100032, China
| | - Xiaoyi Li
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
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Sugoor P, Shah S, Dusane R, Desouza A, Goel M, Shrikhande SV. Proximal gastrectomy versus total gastrectomy for proximal third gastric cancer: total gastrectomy is not always necessary. Langenbecks Arch Surg 2016; 401:687-97. [PMID: 27143021 DOI: 10.1007/s00423-016-1422-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 03/30/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND The appropriate extent of gastric resection for patients with proximal third gastric cancer is controversial. This study addresses whether the choice of surgical strategy (proximal gastrectomy [PG] versus total gastrectomy [TG]) influences the outcomes for proximal third gastric adenocarcinoma. MATERIALS AND METHODS Review of prospective database at Tata Memorial Hospital from January 2010 to December 2012 identified 343 patients diagnosed and treated for gastric cancer. Of these, 75 underwent curative resections with D2 lymphadenectomy for proximal third gastric adenocarcinoma, which entailed proximal gastrectomy in 43 and total gastrectomy in 32 patients, depending on the epicenter of the primary and its relation with the mid-body of the stomach. Morbidity, lymph node yield, resection margins, patterns of recurrence, and survival were compared between these two groups. RESULTS 41/75 tumors were pT3 (23 cases [53.4 %] in the PG and 18 cases [56.3 %] in the TG group). Thirty-six patients [83.7 %] in PG and 29 patients [90.6 %] in TG group received neoadjuvant chemotherapy (NACT). There were no significant differences with regard to median blood loss, general complication rates and length of hospitalization between the two groups. The lymph node yield was comparable between the two procedures [PG = 14; TG = 15]. Positive proximal resection margin rates were comparable between the two groups [PG = 4.7 %; TG = 9.4 %], and there was no statistical difference observed in the distal resection margin positivity rates [PG = 4.7 %; TG = 3.1 %]. Regarding the patterns of recurrence, local recurrence in PG was 4.7 % and there was no local recurrence in the TG group (p = 0.08). Distant recurrence rates was dominant in TG [PG = 30.2 % versus TG = 53.1 %]. The overall 2-year survival following PG and TG was 73.8 and 49.9 %, respectively, and not statistically different (p = 0.10). CONCLUSIONS The extent of resection for proximal third gastric cancer does not influence the clinical outcome. PG and TG have similar survival rates. Both procedures can be accomplished safely. Therefore, PG should be an alternative to TG, even in locally advanced proximal gastric cancers treated by NACT, provided that the tumor size and location permit preservation of adequate remnant of stomach without compromising oncological resection margins. Future QOL studies would further lend credence to the concept of PG for proximal third gastric cancer.
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Affiliation(s)
- Pavan Sugoor
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400 012, India
| | - Sanket Shah
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400 012, India
| | - Rohit Dusane
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400 012, India
| | - Ashwin Desouza
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400 012, India
| | - Mahesh Goel
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400 012, India
| | - Shailesh V Shrikhande
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400 012, India.
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Kinoshita O, Ichikawa D, Ichijo Y, Komatsu S, Okamoto K, Kishimoto M, Yanagisawa A, Otsuji E. Histological evaluation for chemotherapeutic responses of metastatic lymph nodes in gastric cancer. World J Gastroenterol 2015; 21:13500-13506. [PMID: 26730161 PMCID: PMC4690179 DOI: 10.3748/wjg.v21.i48.13500] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 09/22/2015] [Accepted: 10/20/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the effect of preoperative chemotherapy (pre-CTx) for metastatic lymph nodes (MLNs) of gastric cancer (GC).
METHODS: A retrospective cohort of patients with advanced GC, who underwent pre-CTx followed by gastrectomy, was reviewed. The histological tumor regression grade (TRG), which considered the percentage of residual cancer in the visible tumor bed, was applied to primary tumors and individual MLNs: G1a (complete response), G1b (< 10%), G2 (10%-50%) and G3 (> 50%). The clinical response to pre-CTx was retrospectively evaluated using only MLNs information, and we compared the histological and clinical evaluations of MLNs.
RESULTS: Twenty-eight patients were enrolled. A total of 438 MLNs were retrieved, and 22 (5%), 48 (11%), 63 (14%) and 305 (70%) LNs were assigned as G1a, G1b, G2 and G3, respectively. Stratification of the residual MLNs based on the TRGs was as follows: 28 G1b MLNs (9%), 48 G2 MLNs (15%), and 253 G3 MLNs (76%) in the D1 region; 20 (23%), 15 (17%), and 52 (60%) in the D2 region, respectively. However, no significant correlation was found between TRGs in MLNs and clinical response in the subgroup for which evaluation of clinical response was available.
CONCLUSION: Pre-CTx does not provide any outstanding histological benefit for MLNs, and an appropriate D2 lymphadenectomy should routinely be performed to offer the chance of curative resection.
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Adjuvant chemoradiation in gastric cancer: long-term outcomes and prognostic factors from a single institution. TUMORI JOURNAL 2015; 101:517-23. [PMID: 26045120 DOI: 10.5301/tj.5000344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2015] [Indexed: 01/29/2023]
Abstract
BACKGROUND Adjuvant chemoradiotherapy (CRT) improves relapse-free (RFS) and overall survival (OS) in patients with resected gastric cancer. However, difficulties in standardizing an optimal surgical approach and a perceived higher toxicity compared with the perioperative approach have limited its widespread application in Europe. The aim of our study was to assess toxicity and long-term outcomes of adjuvant CRT at our institution. METHODS A retrospective review (September 2001-January 2012) was completed of patients with resected gastric cancer who received adjuvant CRT (Macdonald regimen). Adverse events and completion rates, RFS and OS were estimated. Univariate and multivariate analyses of prognostic factors for OS were performed. RESULTS Eighty-seven patients were included. Most had diffuse (52%) and locally advanced tumors (stage III-IV; 66.7%). D2 lymphadenectomy was performed in 80.5%. The most frequent grade 3-4 toxicities were gastrointestinal (28%) and stomatitis (20%), with 78.2% completing treatment. With a median follow-up of 115 months, 58.5% had relapsed, most of them distantly. Median RFS and OS were 9 and 24 months, respectively. Univariate analysis showed that performance status, stage and lymph node burden were significant factors for OS. In the multivariate study, only stage and lymph node burden remained as independent OS predictors. CONCLUSIONS Our implementation of the Macdonald regimen achieved worse outcomes than those reported in the INT-0116 trial. The rate of distant relapse remains unacceptably high. Higher rate of positive lymph nodes and of diffuse tumors could explain some differences. The use of perioperative chemotherapy, especially in patients with a poorer prognosis, might improve these results.
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Is Laparoscopic Surgery the Standard of Care for GI Luminal Cancer? Indian J Surg 2015; 76:444-52. [PMID: 25614719 DOI: 10.1007/s12262-014-1126-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 06/16/2014] [Indexed: 12/18/2022] Open
Abstract
As surgeons in India strive to keep pace with the technical advances in the field of laparoscopic surgery, we endeavor to evaluate the mounting global evidence regarding laparoscopic gastric and colorectal resections for cancer. We seem to be riding on the crest of excellence in traditional open surgery for gastrointestinal malignancies, opening avenues for research and for the establishment of practice guidelines in laparoscopic surgery. Results from available trials along with those from ongoing studies are paving the path toward the acceptance and standardization of these procedures. What must be ascertained is whether sound oncological principles, which are ultimately exhibited by long-term outcomes, are being preserved while garnering the established benefits of minimally invasive surgery.
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Jeuck TLA, Wittekind C. Gastric carcinoma: stage migration by immunohistochemically detected lymph node micrometastases. Gastric Cancer 2015; 18:100-8. [PMID: 24550066 DOI: 10.1007/s10120-014-0352-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 02/01/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Immunohistochemically detected micrometastases of the regional lymph nodes in previously pN0-classified gastric cancer have been incorporated in the TNM staging system. This study aims to determine the incidence of such micrometastases in gastric carcinoma and to investigate their impact on stage grouping and prognosis. METHODS Ninety-five patients with gastric carcinoma classified as pN0 by conventional histological examination were enrolled. All patients underwent gastric resection with regional lymphadenectomy between 2006 and 2010. A total of 2018 lymph nodes was obtained (median, 20 Lymph nodes) and immunohistostained with anti-pan cytokeratin antibody (KL1). RESULTS Micrometastases were detected in regional lymph nodes by immunohistostaining in 16 out of all 95 patients. Fourteen patients were upstaged by micrometastasis-positive regional lymph nodes. Three patients demonstrated lymph nodes with isolated tumor cells alone. A significantly higher incidence of micrometastases was observed in patients with diffuse histologic type (p = 0.007) and total gastrectomy (p = 0.007). When isolated tumor cells were also regarded as lymph node involvement, the recurrence rate was significantly higher for node-positive than for node-negative patients and for those younger than 70 years (33.3 and 6.7 %, respectively; p = 0.026; n = 39). Overall survival analysis revealed no significant difference between micrometastasis-positive and micrometastasis-negative patients. CONCLUSION Immunohistostaining of regional lymph nodes in node-negative gastric carcinoma patients leads to an increased detection of micrometastases with significant implications for the staging system. Although no impact on survival time was shown, the higher recurrence rate for node-positive patients younger than 70 years indicates a prognostic value of immunohistochemically detectable micrometastases.
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Affiliation(s)
- Theresa L A Jeuck
- Institute of Pathology, University Hospital Leipzig, Liebigstrasse 24, 04103, Leipzig, Germany,
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20
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Shrikhande SV, Sirohi B, Barreto SG, Chacko RT, Parikh PM, Pautu J, Arya S, Patil P, Chilukuri SC, Ganesh B, Kaur T, Shukla D, Rath GS. Indian Council of Medical Research consensus document for the management of gastric cancer. Indian J Med Paediatr Oncol 2014; 35:239-43. [PMID: 25538398 PMCID: PMC4264267 DOI: 10.4103/0971-5851.144970] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The document is based on consensus among the experts and best available evidence pertaining to Indian population and is meant for practice in India. Evaluation of a patient with newly diagnosed gastric cancer should include essential tests: A standard white light endoscopy with multiple biopsies from the tumor for confirmation of the diagnosis, a computed tomography (CT) scan (multi-detector or helical) of the abdomen and pelvis for staging with a CT chest or chest X-ray, and complete blood counts, renal and liver function tests. Endoscopic ultrasonography/ magnetic resonance imaging/positron emission tomography-CT is not recommended for all patients. For early stage disease (IA/B, N0), surgery alone is recommended. The need for adjuvant treatment would be guided by the histopathological analysis of the resected specimen. For locally advanced stage (IB, N+ to IIIC), neoadjuvant chemotherapy may be considered to downstage the disease followed by surgery. This may be followed by adjuvant chemotherapy (as part of the peri-operative chemotherapy regimen) Patients with stage IV/metastatic disease must be assessed for chemotherapy versus best supportive care on an individual basis. Clinical examination including history and physical examination are recommended at each follow-up visit, with a yearly CT scan of the chest, abdomen, and pelvis. HER2 testing should be considered in patients with metastatic disease. 5-FU may be replaced with capecitabine if patients do not have gastric outlet obstruction. Cisplatin may be replaced with oxaliplatin in the regimens.
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Affiliation(s)
- Shailesh V Shrikhande
- Department of Surgical Oncology, Kiran Mazumdar Shaw Cancer Centre, Narayana Health, Bangalore, India
| | - Bhawna Sirohi
- Department of Medical Oncology, Kiran Mazumdar Shaw Cancer Centre, Narayana Health, Bangalore, India
| | - Savio G Barreto
- Institute of Digestive and Hepatobiliary Sciences, Medanta - The Medicity, Gurgaon, Haryana, India
| | - Raju T Chacko
- Department of Medical Oncology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Purvish M Parikh
- Department of Surgical Oncology, Kiran Mazumdar Shaw Cancer Centre, Narayana Health, Bangalore, India
| | - Jeremy Pautu
- Department of Medical Oncology, Mizoram Sate Cancer Institute, Aizwal, Mizoram, India
| | - Supreeta Arya
- Department of Radiodiagnosis, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Prachi Patil
- Department of DDCN, Tata Memorial Centre, Mumbai, Maharashtra, India
| | | | - B Ganesh
- Department of Epidemiology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Tanvir Kaur
- Indian Council of Medical Research, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Shukla
- Indian Council of Medical Research, All India Institute of Medical Sciences, New Delhi, India
| | - Goura Shankar Rath
- Department of Radiotherapy, All India Institute of Medical Sciences, New Delhi, India
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Shum H, Rajdev L. Multimodality management of resectable gastric cancer: A review. World J Gastrointest Oncol 2014; 6:393-402. [PMID: 25320655 PMCID: PMC4197430 DOI: 10.4251/wjgo.v6.i10.393] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 07/01/2014] [Accepted: 09/10/2014] [Indexed: 02/05/2023] Open
Abstract
Adenocarcinoma of the stomach carries a poor prognosis and is the second most common cause of cancer death worldwide. It is recommended that surgical resection with a D1 or a modified D2 gastrectomy (with at least 15 lymph nodes removed for examination) be performed in the United States, though D2 lymphadenectomies should be performed at experienced centers. A D2 lymphadenectomy is the recommended procedure in Asia. Although surgical resection is considered the definitive treatment, rates of recurrences are high, necessitating the need for neoadjuvant or adjuvant therapy. This review article aims to outline and summarize some of the pivotal trials that have defined optimal treatment options for non-metastatic non-cardia gastric cancer. Some of the most notable trials include the INT-0116 trial, which established a benefit in concurrent chemoradiation and adjuvant chemotherapy. This was again confirmed in the ARTIST trial, especially in patients with nodal involvement. Later, the Medical Research Council Adjuvant Gastric Infusional Chemotherapy trial provided evidence for the use of perioperative chemotherapy. Targeted agents such as ramucirumab and trastuzumab are also being investigated for use in locally advanced gastric cancers after demonstrating a benefit in the metastatic setting. Given the poor response rate of this difficult disease to various treatment modalities, numerous studies are currently ongoing in an attempt to define a more effective therapy, some of which are briefly introduced in this review as well.
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Treatment of patients with advanced gastric cancer: experience from an Indian tertiary cancer center. Med Oncol 2014; 31:138. [PMID: 25228200 DOI: 10.1007/s12032-014-0138-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Accepted: 07/12/2014] [Indexed: 12/27/2022]
Abstract
Majority of patients in developing countries diagnosed with gastric cancer have an advanced stage at presentation with overall poor performance status. The aim of the study was to assess outcomes of first- and second-line chemotherapy and determine prognostic factors among patients with advanced gastric cancer (AGC). Using a prospectively maintained database, we identified 144 patients with AGC treated at Tata Memorial Centre between January 2012 and September 2013. Sixteen patients received best supportive care, and 128 patients received palliative chemotherapy. Cox regression was used for multivariate analysis of survival. Of 128 patients, 42(33%) received Cape-Ox, 22(17.1%) EOX and 47(36.7%) DOX while rest received other regimens. PS was 2 in 36 (28%) patients at presentation, and 97% of patients had ≥3 sites of metastasis. Forty-eight patients (37.5%) had signet ring histology. Median follow-up was 9 months. Median progression-free survival/overall survival (OS) was 6/8 months, respectively. Of 93 patients who progressed 39 (41.9%) patients received second-line chemotherapy. Multivariate analysis for OS showed that PS and use of taxane in first-line setting were significant prognostic factors. Patients who received second-line therapy had longer survival than those who did not (12 vs. 6 months; P=0.002). The overall outcome of our patients is comparable to the Western reported data despite an advanced disease at presentation.
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Khan SA, Tyagi M, Sharma AK, Barreto SG, Sirohi B, Ramadwar M, Shrikhande SV, Gupta S. Cell-type specificity of β-actin expression and its clinicopathological correlation in gastric adenocarcinoma. World J Gastroenterol 2014; 20:12202-12211. [PMID: 25232253 PMCID: PMC4161804 DOI: 10.3748/wjg.v20.i34.12202] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2013] [Revised: 03/13/2014] [Accepted: 05/26/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate cell type specific distribution of β-actin expression in gastric adenocarcinoma and its correlation with clinicopathological parameters.
METHODS: β-actin is a housekeeping gene, frequently used as loading control, but, differentially expresses in cancer. In gastric cancer, an overall increased expression of β-actin has been reported using tissue disruptive techniques. At present, no histological data is available to indicate its cell type-specific expression and distribution pattern. In the present study, we analyzed β-actin expression and distribution in paired normal and tumor tissue samples of gastric adenocarcinoma patients using immunohistochemistry (IHC), a tissue non-disruptive technique as well as tissue disruptive techniques like reverse transcriptase-polymerase chain reaction (RT-PCR) and western blotting. Correlation of β-actin level with clinicopathological parameters was done using univariate analysis.
RESULTS: The results of this study showed significant overexpression, at both mRNA and protein level in tumor tissues as confirmed by RT-PCR (1.47 ± 0.13 vs 2.36 ± 0.16; P < 0.001) and western blotting (1.92 ± 0.26 vs 2.88 ± 0.32; P < 0.01). IHC revealed that β-actin expression is majorly distributed between epithelial and inflammatory cells of the tissues. Inflammatory cells showed a significantly higher expression compared to epithelial cells in normal (2.46 ± 0.13 vs 5.92 ± 0.23, P < 0.001), as well as, in tumor tissues (2.79 ± 0.24 vs 6.71 ± 0.14, P < 0.001). Further, comparison of immunostaining between normal and tumor tissues revealed that both epithelial and inflammatory cells overexpress β-actin in tumor tissues, however, significant difference was observed only in inflammatory cells (5.92 ± 0.23 vs 6.71 ± 0.14, P < 0.01). Moreover, combined expression in epithelial and inflammatory cells also showed significant increase (4.19 ± 0.15 vs 4.75 ± 0.14, P < 0.05) in tumor tissues. In addition, univariate analysis showed a positive correlation of β-actin level of inflammatory cells with tumor grade (P < 0.05) while epithelial cells exhibited negative correlation (P > 0.05).
CONCLUSION: In gastric cancer, β-actin showed an overall higher expression predominantly contributed by inflammatory or tumor infiltrating immune cells of the tissue microenvironment and correlates with tumor grade.
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Shrikhande SV, Pai E. Enhanced recovery after surgery in laparoscopic gastric cancer surgery: Many questions, few answers. J Minim Access Surg 2014; 10:105-6. [PMID: 25013324 PMCID: PMC4083540 DOI: 10.4103/0972-9941.134871] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Shailesh V Shrikhande
- Department of Surgical Oncology, Gastrointestinal and Hepato-Pancreato-Biliary Service, GI Disease Management Group, Tata Memorial Centre, Parel, Mumbai - 400 012, Maharashtra, India. E-mail:
| | - Esha Pai
- Department of Surgical Oncology, Gastrointestinal and Hepato-Pancreato-Biliary Service, GI Disease Management Group, Tata Memorial Centre, Parel, Mumbai - 400 012, Maharashtra, India. E-mail:
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