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de Jongh C, van der Meulen MP, Gertsen EC, Brenkman HJF, van Sandick JW, van Berge Henegouwen MI, Gisbertz SS, Luyer MDP, Nieuwenhuijzen GAP, van Lanschot JJB, Lagarde SM, Wijnhoven BPL, de Steur WO, Hartgrink HH, Stoot JHMB, Hulsewe KWE, Spillenaar Bilgen EJ, van Det MJ, Kouwenhoven EA, Daams F, van der Peet DL, van Grieken NCT, Heisterkamp J, van Etten B, van den Berg JW, Pierie JP, Eker HH, Thijssen AY, Belt EJT, van Duijvendijk P, Wassenaar E, Wevers KP, Hol L, Wessels FJ, Haj Mohammad N, Frederix GWJ, van Hillegersberg R, Siersema PD, Vegt E, Ruurda JP. Impact of 18FFDG-PET/CT and Laparoscopy in Staging of Locally Advanced Gastric Cancer: A Cost Analysis in the Prospective Multicenter PLASTIC-Study. Ann Surg Oncol 2024; 31:4005-4017. [PMID: 38526832 PMCID: PMC11076388 DOI: 10.1245/s10434-024-15103-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/12/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Unnecessary D2-gastrectomy and associated costs can be prevented after detecting non-curable gastric cancer, but impact of staging on treatment costs is unclear. This study determined the cost impact of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18FFDG-PET/CT) and staging laparoscopy (SL) in gastric cancer staging. MATERIALS AND METHODS In this cost analysis, four staging strategies were modeled in a decision tree: (1) 18FFDG-PET/CT first, then SL, (2) SL only, (3) 18FFDG-PET/CT only, and (4) neither SL nor 18FFDG-PET/CT. Costs were assessed on the basis of the prospective PLASTIC-study, which evaluated adding 18FFDG-PET/CT and SL to staging advanced gastric cancer (cT3-4 and/or cN+) in 18 Dutch hospitals. The Dutch Healthcare Authority provided 18FFDG-PET/CT unit costs. SL unit costs were calculated bottom-up. Gastrectomy-associated costs were collected with hospital claim data until 30 days postoperatively. Uncertainty was assessed in a probabilistic sensitivity analysis (1000 iterations). RESULTS 18FFDG-PET/CT costs were €1104 including biopsy/cytology. Bottom-up calculations totaled €1537 per SL. D2-gastrectomy costs were €19,308. Total costs per patient were €18,137 for strategy 1, €17,079 for strategy 2, and €19,805 for strategy 3. If all patients undergo gastrectomy, total costs were €18,959 per patient (strategy 4). Performing SL only reduced costs by €1880 per patient. Adding 18FFDG-PET/CT to SL increased costs by €1058 per patient; IQR €870-1253 in the sensitivity analysis. CONCLUSIONS For advanced gastric cancer, performing SL resulted in substantial cost savings by reducing unnecessary gastrectomies. In contrast, routine 18FFDG-PET/CT increased costs without substantially reducing unnecessary gastrectomies, and is not recommended due to limited impact with major costs. TRIAL REGISTRATION NCT03208621. This trial was registered prospectively on 30-06-2017.
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Affiliation(s)
- Cas de Jongh
- Department of Surgery, Medical Oncology and Radiology, University Medical Center (UMC) Utrecht, Utrecht, The Netherlands
| | | | - Emma C Gertsen
- Department of Surgery, Medical Oncology and Radiology, University Medical Center (UMC) Utrecht, Utrecht, The Netherlands
| | - Hylke J F Brenkman
- Department of Surgery, Medical Oncology and Radiology, University Medical Center (UMC) Utrecht, Utrecht, The Netherlands
| | - Johanna W van Sandick
- Surgery and Nuclear Medicine Department, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Mark I van Berge Henegouwen
- Surgery Department, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Surgery and Pathology Department, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Suzanne S Gisbertz
- Surgery Department, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Surgery and Pathology Department, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Misha D P Luyer
- Surgery Department, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | | | - Jan J B van Lanschot
- Surgery and Nuclear Medicine Department, Erasmus Medical Center UMC Rotterdam, Rotterdam, The Netherlands
| | - Sjoerd M Lagarde
- Surgery and Nuclear Medicine Department, Erasmus Medical Center UMC Rotterdam, Rotterdam, The Netherlands
| | - Bas P L Wijnhoven
- Surgery and Nuclear Medicine Department, Erasmus Medical Center UMC Rotterdam, Rotterdam, The Netherlands
| | | | | | - Jan H M B Stoot
- Surgery Department, Zuyderland MC, Sittard-Geleen, The Netherlands
| | | | | | - Marc J van Det
- Surgery Department, ZGT Hospital, Almelo, The Netherlands
| | | | - Freek Daams
- Surgery and Pathology Department, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Surgery and Pathology Department, Location Vrije University, Amsterdam UMC, Amsterdam, The Netherlands
| | - Donald L van der Peet
- Surgery and Pathology Department, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Surgery and Pathology Department, Location Vrije University, Amsterdam UMC, Amsterdam, The Netherlands
| | - Nicole C T van Grieken
- Surgery and Pathology Department, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Surgery and Pathology Department, Location Vrije University, Amsterdam UMC, Amsterdam, The Netherlands
| | - Joos Heisterkamp
- Surgery Department, Elisabeth Twee-Steden Hospital, Tilburg, The Netherlands
| | | | | | - Jean-Pierre Pierie
- Surgery Department, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Hasan H Eker
- Surgery Department, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Annemieke Y Thijssen
- Gastroenterology Department, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Eric J T Belt
- Gastroenterology Department, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | | | - Eelco Wassenaar
- Surgery Department, Gelre Hospitals, Apeldoorn, The Netherlands
| | - Kevin P Wevers
- Surgery Department, Isala Hospital, Zwolle, The Netherlands
| | - Lieke Hol
- Gastroenterology Department, Maasstad Hospital, Rotterdam, The Netherlands
| | - Frank J Wessels
- Department of Surgery, Medical Oncology and Radiology, University Medical Center (UMC) Utrecht, Utrecht, The Netherlands
| | - Nadia Haj Mohammad
- Department of Surgery, Medical Oncology and Radiology, University Medical Center (UMC) Utrecht, Utrecht, The Netherlands
| | - Geert W J Frederix
- Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, Medical Oncology and Radiology, University Medical Center (UMC) Utrecht, Utrecht, The Netherlands
| | - Peter D Siersema
- Gastroenterology and Hepatology Department, Erasmus MC - University Medical Center, Rotterdam, Rotterdam, The Netherlands
| | - Erik Vegt
- Surgery and Nuclear Medicine Department, The Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Surgery and Nuclear Medicine Department, Erasmus Medical Center UMC Rotterdam, Rotterdam, The Netherlands
| | - Jelle P Ruurda
- Department of Surgery, Medical Oncology and Radiology, University Medical Center (UMC) Utrecht, Utrecht, The Netherlands.
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Stroobant EE, Strong VE. Advances in Gastric Cancer Surgical Management. Hematol Oncol Clin North Am 2024; 38:547-557. [PMID: 38402138 DOI: 10.1016/j.hoc.2024.01.003] [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] [Indexed: 02/26/2024]
Abstract
The goal of a gastric cancer operation is a microscopically negative resection margin and D2 lymphadenectomy. Minimally invasive techniques (laparoscopic and robotic) have been proven to be equivalent for oncologic care, yet with faster recovery. Endoscopic mucosal resection can be used for T1a N0 tumor resection. Better understanding of hereditary gastric cancer and molecular subtypes has led to specialized recommendations for MSI-high tumors and patients with pathogenic CDH1 mutations. In the future, surgical management will support minimally invasive approaches and personalized cancer care based on subtype.
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Affiliation(s)
- Emily E Stroobant
- Gastric and Mixed Tumor Service, Department of Surgery - H1216, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Vivian E Strong
- Gastric and Mixed Tumor Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; Weill Cornell Medical College of Cornell University, 1300 York Avenue, New York, NY, 10065, USA.
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3
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Kroese TE, Bronzwaer S, van Rossum PSN, Schoppman SF, Deseyne PRAJ, van Cutsem E, Haustermans K, Nafteux P, Thomas M, Obermannova R, Mortensen HR, Nordsmark M, Pfeiffer P, Elme A, Adenis A, Piessen G, Bruns CJ, Lordick F, Gockel I, Moehler M, Gani C, Liakakos T, Reynolds JV, Morganti AG, Rosati R, Castoro C, Cellini F, D'Ugo D, Roviello F, Bencivenga M, de Manzoni G, van Berge Henegouwen MI, Hulshoff MCCM, van Dieren J, Vollebergh M, van Sandick JW, Jeene P, Muijs C, Slingerland M, Voncken FEM, Hartgrink H, Creemers GJ, van der Sangen MJC, Nieuwenhuijzen GAP, Berbee M, Verheij M, Wijnhoven B, Beerepoot LV, Mohammad NH, Mook S, Ruurda JP, Kolodziejczyk P, Polkowski WP, Wyrwicz L, Alsina M, Tabernero J, Pera M, Kanonnikoff TF, Cervantes A, Nilsson M, Monig S, Wagner AD, Guckenberger M, Griffiths EA, Smyth E, Hanna GB, Markar S, Chaudry MA, Hawkins MA, Cheong E, van Laarhoven HWM, van Hillegersberg R. European clinical practice guidelines for the definition, diagnosis, and treatment of oligometastatic esophagogastric cancer (OMEC-4). Eur J Cancer 2024; 204:114062. [PMID: 38678762 DOI: 10.1016/j.ejca.2024.114062] [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: 12/15/2023] [Revised: 03/28/2024] [Accepted: 04/06/2024] [Indexed: 05/01/2024]
Abstract
INTRODUCTION The OligoMetastatic Esophagogastric Cancer (OMEC) project aims to provide clinical practice guidelines for the definition, diagnosis, and treatment of esophagogastric oligometastatic disease (OMD). METHODS Guidelines were developed according to AGREE II and GRADE principles. Guidelines were based on a systematic review (OMEC-1), clinical case discussions (OMEC-2), and a Delphi consensus study (OMEC-3) by 49 European expert centers for esophagogastric cancer. OMEC identified patients for whom the term OMD is considered or could be considered. Disease-free interval (DFI) was defined as the time between primary tumor treatment and detection of OMD. RESULTS Moderate to high quality of evidence was found (i.e. 1 randomized and 4 non-randomized phase II trials) resulting in moderate recommendations. OMD is considered in esophagogastric cancer patients with 1 organ with ≤ 3 metastases or 1 involved extra-regional lymph node station. In addition, OMD continues to be considered in patients with OMD without progression in number of metastases after systemic therapy. 18F-FDG PET/CT imaging is recommended for baseline staging and for restaging after systemic therapy when local treatment is considered. For patients with synchronous OMD or metachronous OMD and a DFI ≤ 2 years, recommended treatment consists of systemic therapy followed by restaging to assess suitability for local treatment. For patients with metachronous OMD and DFI > 2 years, upfront local treatment is additionally recommended. DISCUSSION These multidisciplinary European clinical practice guidelines for the uniform definition, diagnosis and treatment of esophagogastric OMD can be used to standardize inclusion criteria in future clinical trials and to reduce variation in treatment.
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Affiliation(s)
- Tiuri E Kroese
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Sebastiaan Bronzwaer
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - Peter S N van Rossum
- Department of Radiation Oncology, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
| | - Sebastian F Schoppman
- Department of Surgery, Medical University of Vienna, Vienna University, Vienna, Austria
| | - Pieter R A J Deseyne
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium; Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Eric van Cutsem
- Department of Medical Oncology, KU Leuven, Leuven University, Leuven, Belgium
| | - Karin Haustermans
- Department of Radiation Oncology, KU Leuven, Leuven University, Leuven, Belgium
| | - Philippe Nafteux
- Department of Surgery, KU Leuven, Leuven University, Leuven, Belgium
| | - Melissa Thomas
- Department of Radiation Oncology, AZ Sint-Maarten, Mechelen, Belgium
| | - Radka Obermannova
- Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute and Faculty of Medicine, Masaryk, University Brno, Brno, Czech Republic
| | - Hanna R Mortensen
- Danish Center of Particle Therapy, Aarhus University Medical Center, Aarhus University, Aarhus, Denmark
| | - Marianne Nordsmark
- Department of Oncology, Aarhus University Hospital, Aarhus University, Aarhus, Denmark
| | - Per Pfeiffer
- Department of Medical Oncology, Odense University Medical Center, University of Odense, Odense, Denmark
| | - Anneli Elme
- Department of Medical Oncology, Tallinn University Hospital, Tallinn University, Tallinn, Estonia
| | - Antoine Adenis
- Department of Medical Oncology, IRCM, Inserm, Université Montpellier, ICM, Montpellier, France
| | - Guillaume Piessen
- Department of Surgery, Univ. Lille, CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity Plasticity and Resistance to Therapies, F-59000 Lille, France
| | - Christiane J Bruns
- Department of Surgery, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Florian Lordick
- Department of Medical Oncology, University Hospital Leipzig, University of Leipzig, Leipzig Germany
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, University of Leipzig, Leipzig, Germany
| | - Markus Moehler
- Department of Medicine, Johannes Gutenberg-University Clinic, University of Mainz, Mainz, Germany
| | - Cihan Gani
- Department of Radiation Oncology, University Hospital Tubingen, University of Tubingen, Tubingen, Germany
| | - Theodore Liakakos
- Department of Surgery, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - John V Reynolds
- Trinity St James's Cancer Institute, St. James Hospital, Trinity College Dublin, Dublin, Ireland
| | - Alessio G Morganti
- Department of Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Radiation Oncology, DIMES, Alma Mater Studiorum - Bologna University, Bologna, Italy
| | - Riccardo Rosati
- Department of GI Surgery, IRCCS San Raffaele Scientific Institute, San Raffaele Vita-salute University, Milan, Italy
| | - Carlo Castoro
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan 20072, Italy; Upper GI and General Surgery Division, Department of Surgery IRCCS Humanitas Research Hospital, via Manzoni 56, Rozzano, Milan 20089, Italy
| | - Francesco Cellini
- Università Cattolica del Sacro Cuore, Dipartimento Universitario Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Roma, Italy; Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italy
| | - Domenico D'Ugo
- Department of Surgery, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Franco Roviello
- Department of Surgery, Siena University Hospital, University of Siena, Siena, Italy
| | - Maria Bencivenga
- General and Upper GI Division, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Giovanni de Manzoni
- General and Upper GI Division, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Maarten C C M Hulshoff
- Department of Radiation Oncology, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
| | - Jolanda van Dieren
- Department of Gastrointestinal Oncology, Antoni van Leeuwenhoek, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Marieke Vollebergh
- Department of Medical Oncology, Antoni van Leeuwenhoek, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Johanna W van Sandick
- Department of Surgery, Antoni van Leeuwenhoek, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Paul Jeene
- Department of Radiation Oncology, Radiotherapiegroep, Deventer, the Netherlands
| | - Christel Muijs
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Marije Slingerland
- Department of Medical Oncology, University Medical Center Leiden, University of Leiden, Leiden, the Netherlands
| | - Francine E M Voncken
- Department of Radiation Oncology, University Medical Center Leiden, University of Leiden, Leiden, the Netherlands
| | - Henk Hartgrink
- Department of Surgery, University Medical Center Leiden, University of Leiden, Leiden, the Netherlands
| | - Geert-Jan Creemers
- Department of Medical Oncology, Catharina Cancer Institute, Eindhoven, the Netherlands
| | | | | | - Maaike Berbee
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht, the Netherlands
| | - Marcel Verheij
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Bas Wijnhoven
- Department of Surgery, Erasmus University Medical Center, University of Rotterdam, Rotterdam, the Netherlands
| | - Laurens V Beerepoot
- Department of Medical Oncology, Elisabeth Tweesteden Ziekenhuis Tilburg, the Netherlands
| | - Nadia Haj Mohammad
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Stella Mook
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Piotr Kolodziejczyk
- Department of Surgery Jagiellonian University Medical College, Krakow, Poland
| | | | - Lucjan Wyrwicz
- Department of Oncology and Radiotherapy, Maria Skłodowska-Curie Institute, Warsaw, Poland
| | - Maria Alsina
- Department of Medical Oncology, Hospital Universitario de Navarra (HUN) and Navarrabiomed - Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | - Josep Tabernero
- Department of Medical Oncology, Vall D'Hebron Hospital Campus and Vall D'Hebron Institute of Oncology (VHIO), CIBERONC, Barcelona, Spain
| | - Manuel Pera
- Department of Surgery, Hospital del Mar, Universitat Autònoma de Barcelona, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Tania F Kanonnikoff
- Department of Medical Oncology, Hospital Clinico Universitario de Valencia, University of Valencia, Incliva Biomedical Research Institute, Valencia, Spain
| | - Andrés Cervantes
- Department of Medical Oncology, Hospital Clinico Universitario de Valencia, University of Valencia, Incliva Biomedical Research Institute, Valencia, Spain
| | - Magnus Nilsson
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, and Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Stefan Monig
- Department of Surgery, University Hospital Geneva, University of Geneva, Geneva, Switzerland
| | - Anna D Wagner
- Department of Oncology, Division of Medical Oncology, University Hospital of Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospital Birmingham, Birmingham, United Kingdom
| | - Elizabeth Smyth
- Department of Oncology, Cambridge University Hospitals, Cambridge University, Cambridge, United Kingdom
| | - George B Hanna
- Nuffield Department of Surgical Sciences, University of Oxford, United Kingdom, Department of Surgery, Imperial College London, London University, London, United Kingdom
| | - Sheraz Markar
- Nuffield Department of Surgical Sciences, University of Oxford, United Kingdom, Department of Surgery, Imperial College London, London University, London, United Kingdom
| | - M Asif Chaudry
- Department of GI Cancer & Surgery, The Royal Marsden Hospital & Institute of Cancer Research University of London, London, United Kingdom
| | - Maria A Hawkins
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Edward Cheong
- Department of Upper GI and General Surgery, PanAsia Surgery, Singapore
| | - Hanneke W M van Laarhoven
- Amsterdam UMC location University of Amsterdam, Department of Medical Oncology, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
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4
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van der Sluis K, van Sandick JW, Vollebergh MA, van Dieren JM, Hugen N, Hartemink KJ, Veenhof AAFA, Verhoeven E, van den Berg JG, Snaebjornsson P, Noe M, van Wezel T, Boelens MC, Kodach LL. Improving diagnostic accuracy of identifying gastric cancer patients with peritoneal metastases: tumor-guided cell-free DNA analysis of peritoneal fluid. Oncogene 2024:10.1038/s41388-024-03034-z. [PMID: 38654110 DOI: 10.1038/s41388-024-03034-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 04/09/2024] [Accepted: 04/11/2024] [Indexed: 04/25/2024]
Abstract
Detection of peritoneal dissemination (PD) in gastric cancer (GC) patients remains challenging. The feasibility of tumor-guided cell-free DNA (cfDNA) detection in prospectively collected peritoneal fluid (ascites and peritoneal lavage) was investigated and compared to conventional cytology in 28 patients. Besides conventional cytology, next generation sequencing was performed on primary tumor DNA and cell-free DNA from peritoneal fluid. Patients were retrospectively grouped into: a positive group (with PD) and a negative group (without PD). Detectable mutations were found in the primary tumor of 68% (n = 19). Sensitivity of PD detection by tumor-guided cfDNA analysis was 91%, compared to 64% by conventional cytology. Within the positive group (n = 11), tumor-guided cfDNA was detected in all patients with ascites samples (4/4, 100%) and in 86% (6/7) of the lavage samples, opposed to 4/4 (100%) patients with ascites and 43% (3/7) with lavage by conventional cytology. Within the negative group (n = 8), conventional cytology was negative for all samples. In two patients, tumor-guided cfDNA was detected in peritoneal lavage fluid. Interestingly, these 2 patients developed PD within 6 months, suggesting a prognostic value of tumor-guided cfDNA detection. This study showed that tumor-guided cfDNA detection in peritoneal fluids of GC patients is feasible and superior to conventional cytology in detecting PD.
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Affiliation(s)
- Karen van der Sluis
- The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Department of Surgical Oncology, Amsterdam, The Netherlands
| | - Johanna W van Sandick
- The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Department of Surgical Oncology, Amsterdam, The Netherlands
| | - Marieke A Vollebergh
- The Netherlands Cancer Institute- Antoni van Leeuwenhoek, Department of Gastrointestinal Oncology, Amsterdam, The Netherlands
| | - Jolanda M van Dieren
- The Netherlands Cancer Institute- Antoni van Leeuwenhoek, Department of Gastrointestinal Oncology, Amsterdam, The Netherlands
| | - Niek Hugen
- The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Department of Surgical Oncology, Amsterdam, The Netherlands
| | - Koen J Hartemink
- The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Department of Surgical Oncology, Amsterdam, The Netherlands
| | - Alexander A F A Veenhof
- The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Department of Surgical Oncology, Amsterdam, The Netherlands
| | - Els Verhoeven
- The Netherlands Cancer Institute- Antoni van Leeuwenhoek, Department of Pathology, Amsterdam, The Netherlands
| | - José G van den Berg
- The Netherlands Cancer Institute- Antoni van Leeuwenhoek, Department of Pathology, Amsterdam, The Netherlands
| | - Petur Snaebjornsson
- The Netherlands Cancer Institute- Antoni van Leeuwenhoek, Department of Pathology, Amsterdam, The Netherlands
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Michael Noe
- The Netherlands Cancer Institute- Antoni van Leeuwenhoek, Department of Pathology, Amsterdam, The Netherlands
| | - Tom van Wezel
- The Netherlands Cancer Institute- Antoni van Leeuwenhoek, Department of Pathology, Amsterdam, The Netherlands
| | - Mirjam C Boelens
- The Netherlands Cancer Institute- Antoni van Leeuwenhoek, Department of Pathology, Amsterdam, The Netherlands
| | - Liudmila L Kodach
- The Netherlands Cancer Institute- Antoni van Leeuwenhoek, Department of Pathology, Amsterdam, The Netherlands.
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5
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Morgagni P, Bencivenga M, Carneiro F, Cascinu S, Derks S, Di Bartolomeo M, Donohoe C, Eveno C, Gisbertz S, Grimminger P, Gockel I, Grabsh H, Kassab P, Langer R, Lonardi S, Maltoni M, Markar S, Moehler M, Marrelli D, Mazzei MA, Melisi D, Milandri C, Moenig PS, Mostert B, Mura G, Polkowski W, Reynolds J, Saragoni L, Van Berge Henegouwen MI, Van Hillegersberg R, Vieth M, Verlato G, Torroni L, Wijnhoven B, Tiberio GAM, Yang HK, Roviello F, de Manzoni G. International consensus on the management of metastatic gastric cancer: step by step in the foggy landscape : Bertinoro Workshop, November 2022. Gastric Cancer 2024:10.1007/s10120-024-01479-5. [PMID: 38634954 DOI: 10.1007/s10120-024-01479-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 02/05/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Many gastric cancer patients in Western countries are diagnosed as metastatic with a median overall survival of less than twelve months using standard chemotherapy. Innovative treatments, like targeted therapy or immunotherapy, have recently proved to ameliorate prognosis, but a general agreement on managing oligometastatic disease has yet to be achieved. An international multi-disciplinary workshop was held in Bertinoro, Italy, in November 2022 to verify whether achieving a consensus on at least some topics was possible. METHODS A two-round Delphi process was carried out, where participants were asked to answer 32 multiple-choice questions about CT, laparoscopic staging and biomarkers, systemic treatment for different localization, role and indication of palliative care. Consensus was established with at least a 67% agreement. RESULTS The assembly agreed to define oligometastases as a "dynamic" disease which either regresses or remains stable in response to systemic treatment. In addition, the definition of oligometastases was restricted to the following sites: para-aortic nodal stations, liver, lung, and peritoneum, excluding bones. In detail, the following conditions should be considered as oligometastases: involvement of para-aortic stations, in particular 16a2 or 16b1; up to three technically resectable liver metastases; three unilateral or two bilateral lung metastases; peritoneal carcinomatosis with PCI ≤ 6. No consensus was achieved on how to classify positive cytology, which was considered as oligometastatic by 55% of participants only if converted to negative after chemotherapy. CONCLUSION As assessed at the time of diagnosis, surgical treatment of oligometastases should aim at R0 curativity on the entire disease volume, including both the primary tumor and its metastases. Conversion surgery was defined as surgery on the residual volume of disease, which was initially not resectable for technical and/or oncological reasons but nevertheless responded to first-line treatment.
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Affiliation(s)
- Paolo Morgagni
- Department of General Surgery, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Maria Bencivenga
- General and Upper GI Surgery, Department of Surgery, University Hospital Verona, University of Verona, Verona, Italy.
| | - Fatima Carneiro
- Department of Pathology, Centro Hospitalar de São João, Institute of Molecular Pathology and Immunology of the University of Porto (Ipatimup), Porto, Portugal
| | - Stefano Cascinu
- Department of Medical Oncology, Comprehensive Cancer Center, Università Vita-Salute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Sarah Derks
- Department of Medical Oncology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Maria Di Bartolomeo
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Claire Donohoe
- Medicinal Chemistry, Trinity Translational Medicine Institute, Trinity Centre for Health Sciences, Trinity College Dublin, The University of Dublin, St. James's Hospital, Dublin 8, Ireland
| | - Clarisse Eveno
- Department of Digestive and Oncologic Surgery, Claude Huriez University Hospital, Centre Hospitalier Universitaire (CHU) Lille, Université de Lille, Lille, France
| | - Suzanne Gisbertz
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter Grimminger
- Department of General, Visceral and Transplant Surgery, University Medical Center, University of Mainz, Mainz, Germany
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Heike Grabsh
- Department of Pathology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
- Pathology and Data Analytics, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, United Kingdom
| | - Paulo Kassab
- Gastric Surgery Division, BP Gastric Surgery Department, Santa Casa Medical School, São Paulo, Brazil
| | - Rupert Langer
- Institute of Pathology and Microbiology, Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
| | - Sara Lonardi
- Istituto Oncologico Veneto IOV-IRCCS, Padua, Italy
| | - Marco Maltoni
- Unit of Palliative Care, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Forlì-Cesena, Italy
| | - Sheraz Markar
- Surgical Interventional Trials Unit, University of Oxford, Oxford, UK
| | - Markus Moehler
- Department of Medicine, Johannes-Gutenberg University Clinic, Mainz, Germany
| | - Daniele Marrelli
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, 53100, Siena, Italy
| | - Maria Antonietta Mazzei
- Unit of Diagnostic Imaging, Department of Medical, Surgical and Neuro Sciences and of Radiological Sciences, Azienda Ospedaliero-Universitaria Senese, University of Siena, 53100, Siena, Italy
| | - Davide Melisi
- Medical Oncology at the Department of Medicine, University of Verona, Verona, Italy
| | - Carlo Milandri
- Department of Oncology, San Donato Hospital, 52100, Arezzo, Italy
| | | | - Bianca Mostert
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Gianni Mura
- Department of Surgery, San Donato Hospital, Arezzo, Italy
| | - Wojciech Polkowski
- Department of Surgical Oncology, Medical University of Lublin, Radziwiłłowska 13 St, 20-080, Lublin, Poland
| | | | - Luca Saragoni
- Pathology Unit, Santa Maria delle Croci Ravenna Hospital, Ravenna, Italy
| | - Mark I Van Berge Henegouwen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Michael Vieth
- Institute of Pathology, Klinikum Bayreuth, Bayreuth, Germany
| | - Giuseppe Verlato
- Department of Diagnostics and Public Health, Section of Epidemiology and Medical Statistics, University of Verona, Verona, Italy
| | - Lorena Torroni
- Department of Diagnostics and Public Health, Section of Epidemiology and Medical Statistics, University of Verona, Verona, Italy
| | - Bas Wijnhoven
- Department of Surgery, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, Netherlands
| | | | - Han-Kwang Yang
- Surgical Department, SNUH National Cancer Center, Seoul, Korea
| | - Franco Roviello
- Unit of General Surgery and Surgical Oncology, Department of Medicine Surgery and Neurosciences, University of Siena, 53100, Siena, Italy
| | - Giovanni de Manzoni
- General and Upper GI Surgery, Department of Surgery, University Hospital Verona, University of Verona, Verona, Italy
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6
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van Hootegem SJM, Chmelo J, van der Sluis PC, Lagarde SM, Phillips AW, Wijnhoven BPL. The yield of diagnostic laparoscopy with peritoneal lavage in gastric adenocarcinoma: A retrospective cohort study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108233. [PMID: 38428107 DOI: 10.1016/j.ejso.2024.108233] [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: 10/20/2023] [Revised: 01/24/2024] [Accepted: 02/25/2024] [Indexed: 03/03/2024]
Abstract
INTRODUCTION Diagnostic laparoscopy (DL) with peritoneal lavage has been adopted as a standard staging procedure for patients with gastric cancer (GC). Evaluation of the value of DL is important given ongoing improvements in diagnostic imaging and treatment. As contemporary data from European centres are sparse, this retrospective cohort study aimed to assess the yield of DL in patients with potentially curable gastric cancer, and to identify predictive factors for peritoneal metastases. METHODS Patients with adenocarcinoma of the stomach, treated between January 2016 and December 2018, were identified from institutional databases of two high volume European Upper-GI centres. Patients who underwent a DL with peritoneal lavage for potentially curable disease after clinical staging with imaging (cT1-4N0-3M0) were included. The primary outcome was the proportion of patients with a positive DL, defined as macroscopic metastatic disease, positive peritoneal cytology washings (PC+) or locally irresectable disease. RESULTS Some 80 of 327 included patients (24.5%) had a positive DL, excluding these patients from neoadjuvant treatment (66 of 327; 20.2%) and/or surgical resection (76 of 327; 23.2%). In 34 of 327 patients (10.3%), macroscopic metastatic disease was seen, with peritoneal deposits in 30 of these patients. Only 16 of 30 patients with peritoneal disease had positive cytology. Some 41 of 327 patients (12.5%) that underwent DL had PC+ in the absence of macroscopic metastases and five patients (1.5%) had an irresectable primary tumour. Diffuse type carcinoma had the highest risk of peritoneal dissemination, irrespective of cT and cN categories. CONCLUSION The diagnostic yield of staging laparoscopy is high, changing the management in approximately one quarter of patients. DL should be considered in patients with diffuse type carcinoma irrespective of cT and cN categories.
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Affiliation(s)
- S J M van Hootegem
- Department of Surgery, Erasmus MC University, Rotterdam, the Netherlands.
| | - J Chmelo
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle-Upon-Tyne, UK
| | - P C van der Sluis
- Department of Surgery, Erasmus MC University, Rotterdam, the Netherlands
| | - S M Lagarde
- Department of Surgery, Erasmus MC University, Rotterdam, the Netherlands
| | - A W Phillips
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle-Upon-Tyne, UK; School of Medical Education, Newcastle University, UK
| | - B P L Wijnhoven
- Department of Surgery, Erasmus MC University, Rotterdam, the Netherlands
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7
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Rijken A, Pape M, Simkens GA, de Hingh IHJT, Luyer MDP, van Sandick JW, van Laarhoven HWM, Verhoeven RHA, van Erning FN. Peritoneal metastases from gastric cancer in a nationwide cohort: Incidence, treatment and survival. Int J Cancer 2024; 154:992-1002. [PMID: 37916797 DOI: 10.1002/ijc.34780] [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: 04/22/2023] [Revised: 09/28/2023] [Accepted: 10/06/2023] [Indexed: 11/03/2023]
Abstract
The aims of this study were to investigate incidence, risk factors and treatment of synchronous or metachronous peritoneal metastases (PM) from gastric cancer and to estimate survival of these patients using population-based data. Patients diagnosed with gastric cancer in 2015 to 2016 were selected from the Netherlands Cancer Registry. The incidence of synchronous and metachronous PM were calculated. Multivariable regression analyses were performed to identify factors associated with the occurrence of PM. Treatment and survival were compared between patients with synchronous and metachronous PM. Of 2206 patients with gastric cancer, 741 (34%) were diagnosed with PM. Of these, 498 (23%) had synchronous PM. The cumulative incidence of metachronous PM in patients who underwent potentially curative treatment (n = 675) was 22.8% at 3 years. A factor associated with synchronous and metachronous PM was diffuse type histology. Patients diagnosed with synchronous PM more often received systemic treatment than patients with metachronous PM (35% vs 18%, respectively, P < .001). Median overall survival was comparable between synchronous and metachronous PM (3.2 vs 2.3 months, respectively, P = .731). Approximately one third of all patients with gastric cancer are diagnosed with PM, either at primary diagnosis or during 3-year follow-up after potentially curative treatment. Patients with metachronous PM less often received systemic treatment than those with synchronous PM but survival was comparable between both groups. Future trials are warranted to detect gastric cancer at an earlier stage and to examine strategies that lower the risk of peritoneal dissemination. Also, specific treatment options for patients with gastric PM should be further investigated.
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Affiliation(s)
- Anouk Rijken
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
| | - Marieke Pape
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
- Amsterdam UMC location University of Amsterdam, Medical Oncology, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
| | - Geert A Simkens
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Ignace H J T de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
- GROW-School for Oncology and Development Biology, Maastricht University, Maastricht, the Netherlands
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Johanna W van Sandick
- Department of Surgery, Antoni van Leeuwenhoek - Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Hanneke W M van Laarhoven
- Amsterdam UMC location University of Amsterdam, Medical Oncology, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
| | - Rob H A Verhoeven
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
- Amsterdam UMC location University of Amsterdam, Medical Oncology, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
| | - Felice N van Erning
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
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8
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Acs M, Piso P, Glockzin G. Peritoneal Metastatic Gastric Cancer: Local Treatment Options and Recommendations. Curr Oncol 2024; 31:1445-1459. [PMID: 38534942 PMCID: PMC10969192 DOI: 10.3390/curroncol31030109] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/29/2024] [Accepted: 03/07/2024] [Indexed: 05/26/2024] Open
Abstract
Peritoneal metastasis is a common finding in patients with advanced gastric cancer. Beyond systemic chemotherapy, additive local treatments such as cytoreductive surgery and intraperitoneal chemotherapy are considered an inherent part of different multimodal treatment concepts for selected patients with peritoneal metastatic gastric cancer. This review article discusses the role of cytoreductive surgery (CRS) and intraperitoneal chemotherapy, including HIPEC, NIPS, and PIPAC, as additive therapeutic options with curative and palliative intent.
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Affiliation(s)
- Miklos Acs
- Department of Surgery, University Medical Center Regensburg, 93053 Regensburg, Germany;
| | - Pompiliu Piso
- Department of Surgery, Krankenhaus Barmherzige Brueder Regensburg, 93049 Regensburg, Germany;
| | - Gabriel Glockzin
- Department of Surgery, Muenchen Klinik Bogenhausen, 81925 Munich, Germany
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9
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Van Der Sluis K, Taylor SN, Kodach LL, van Dieren JM, de Hingh IHJT, Wijnhoven BPL, Verhoeven RHA, Vollebergh MA, van Sandick JW. Tumor-positive peritoneal cytology in patients with gastric cancer is associated with poor outcome: A nationwide study. Eur J Cancer 2024; 199:113541. [PMID: 38237371 DOI: 10.1016/j.ejca.2024.113541] [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: 11/10/2023] [Revised: 12/14/2023] [Accepted: 01/05/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND The clinical significance of tumor-positive peritoneal cytology (CYT+) in gastric cancer (GC) patients is unclear. This nationwide cohort study aimed to i) assess the frequency of cytological analysis at staging laparoscopy; ii) determine the prevalence of CYT+GC; and iii) compare overall survival (OS) in CYT+ patients versus those with (PM+) and those without (PM-) macroscopic peritoneal disease. METHODS All patients diagnosed with cT1-4, cN0-2 and M0 or synchronous PM GC between 2016-2021 were identified in the Netherlands Cancer Registry database and linked to the nationwide pathology database. RESULTS A total of 4397 patients was included, of which 40 % underwent cytological assessment following staging laparoscopy (863/1745). The prevalence of CYT+ was 8 %. A total of 69 patients had CYT+(1.6 %), 789 (17.9 %) had PM+ and 3539 (80.5 %) had PM- disease. Hazard ratio for OS in CYT+ versus PM+ was 0.86 (95 %CI 0.64-1.17, p-value=0.338), and in PM- versus PM+0.43 (95 %CI 0.38-0.49, p-value<0.001). No survival difference was found between systemic chemotherapy versus surgical resection in CYT+ patients. DISCUSSION In this nationwide study, OS for gastric cancer patients with CYT+ was equally unfavorable as for those with PM+ and significantly worse as compared to those with PM-. The optimal treatment strategy has yet to be established.
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Affiliation(s)
- Karen Van Der Sluis
- The Netherlands Cancer Institute, Department of Surgical Oncology, Amsterdam, the Netherlands.
| | - Steven N Taylor
- The Netherlands Cancer Institute, Department of Surgical Oncology, Amsterdam, the Netherlands
| | - Liudmila L Kodach
- The Netherlands Cancer Institute, Department of Pathology, Amsterdam, the Netherlands
| | - Jolanda M van Dieren
- The Netherlands Cancer Institute, Department of Gastrointestinal Oncology, Amsterdam, the Netherlands
| | | | - Bas P L Wijnhoven
- Erasmus Medical Centre, Department of Surgery, Rotterdam, the Netherlands
| | - Rob H A Verhoeven
- Netherlands Comprehensive Cancer Organization (IKNL), Department of Research & Development, Utrecht, the Netherlands; Amsterdam UMC location University of Amsterdam, Medical Oncology, Meibergdreef 9, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
| | - Marieke A Vollebergh
- The Netherlands Cancer Institute, Department of Gastrointestinal Oncology, Amsterdam, the Netherlands
| | - Johanna W van Sandick
- The Netherlands Cancer Institute, Department of Surgical Oncology, Amsterdam, the Netherlands
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Acs M, Babucke M, Jusufi M, Kaposztas Z, Slowik P, Hornung M, Schlitt HJ, Panczel I, Hevesi J, Herzberg J, Strate T, Piso P. Current clinical practices of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Innov Surg Sci 2024; 9:3-15. [PMID: 38826635 PMCID: PMC11138857 DOI: 10.1515/iss-2023-0055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 12/20/2023] [Indexed: 06/04/2024] Open
Abstract
Treatment of peritoneal surface malignancies makes physicians face demanding and new-fangled problems, as there are many uncertain aspects considering the outcomes of affected patients' prognoses. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are associated with favorable long-term outcomes in carefully selected patients with peritoneal metastases (PM). We aim to summarize the current results about the initial malignancies and their peritoneal spreads. The current literature has been scrutinized, and studies between 2016 and 2022 were included wherein long-term, progression-free (PFS), and overall survival (OS) data were considered relevant information. Medline, Embase, and Google Scholar have been the main sources. Hereby, we cover all the primer malignancies: gastric, ovarian, and colorectal cancers with peritoneal metastases (PM), malignant peritoneal mesothelioma, and pseudomyxoma peritonei. Examining the advances in the current peer-reviewed literature about the indications of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), target groups, risk factors, and other influencing elements, we intend to provide a complex state-of-the-art report, establishing the relevant aspects of that emerging treatment method.
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Affiliation(s)
- Miklos Acs
- Department of General and Visceral Surgery, Hospital Barmherzige Brüder, Regensburg, Germany
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Maximilian Babucke
- Department of General and Visceral Surgery, Hospital Barmherzige Brüder, Regensburg, Germany
| | - Maximilian Jusufi
- Department of General and Visceral Surgery, AK Barmbek, Hamburg, Germany
| | - Zsolt Kaposztas
- Department of Surgery, Somogy County Kaposi Mor Teaching Hospital, Kaposvar, Hungary
| | - Przemyslaw Slowik
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Matthias Hornung
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Hans J. Schlitt
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Ivan Panczel
- Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | | | - Jonas Herzberg
- Department of Surgery, Krankenhaus Reinbek St. Adolf-Stift, Reinbek, Germany
| | - Tim Strate
- Department of Surgery, Krankenhaus Reinbek St. Adolf-Stift, Reinbek, Germany
| | - Pompiliu Piso
- Department of General and Visceral Surgery, Hospital Barmherzige Brüder, Regensburg, Germany
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11
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Lin T, Chen X, Xu Z, Hu Y, Liu H, Yu J, Li G. Laparoscopic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for gastric cancer with intraoperative detection of limited peritoneal metastasis: a Phase II study of CLASS-05 trial. Gastroenterol Rep (Oxf) 2024; 12:goae001. [PMID: 38390578 PMCID: PMC10882263 DOI: 10.1093/gastro/goae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 10/05/2023] [Accepted: 12/31/2023] [Indexed: 02/24/2024] Open
Abstract
Background Systemic chemotherapy for gastric cancer with peritoneal metastasis has limited clinical benefit; for those with intraoperative detection of occult peritoneal metastasis, cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy (HIPEC) is an alternative treatment. However, the feasibility and effects of this modality and criteria for selecting suitable groups remain unclear. This study aimed to explore the safety and efficacy of laparoscopic cytoreductive surgery (L-CRS) followed by HIPEC in gastric cancer with limited peritoneal metastasis, and this study also aimed to determine the optimized cut-off of the peritoneal cancer index. Methods Between March 2017 and November 2019, patients diagnosed with gastric cancer peritoneal metastases by using laparoscopy and the Sugarbaker peritoneal cancer index of ≤12 were eligible for inclusion. All patients received L-CRS (including gastrectomy with D2 lymph node dissection) and resection of visible peritoneal metastasis, followed by post-operative HIPEC, and systemic chemotherapy. The primary end points were median progression-free survival and median survival time, and the secondary outcomes were morbidity and mortality within 30 days after surgery. Results Thirty patients were eligible for analysis, of whom 19 (63.3%) were female, and the overall mean age was 53.0 years. The post-operative morbidity was 20% and the severe complication rate was 10%. The median survival time was 27.0 months with a 2-year overall survival rate of 52.3% and median progression-free survival was 14.0 months with a 2-year progression-free survival of 30.4%. Conclusions L-CRS followed by HIPEC can be safely performed for gastric cancer with limited peritoneal metastasis and potential survival benefits.
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Affiliation(s)
- Tian Lin
- Department of General Surgery & Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, P. R. China
| | - Xinhua Chen
- Department of General Surgery & Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, P. R. China
| | - Zhijun Xu
- Department of General Surgery & Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, P. R. China
| | - Yanfeng Hu
- Department of General Surgery & Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, P. R. China
| | - Hao Liu
- Department of General Surgery & Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, P. R. China
| | - Jiang Yu
- Department of General Surgery & Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, P. R. China
| | - Guoxin Li
- Department of General Surgery & Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, P. R. China
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12
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Li AY, Sedighim S, Tajik F, Khan AM, Radhakrishnan VK, Dayyani F, Senthil M. Regional Therapy Approaches for Gastric Cancer with Limited Peritoneal Disease. J Gastrointest Cancer 2024:10.1007/s12029-023-00994-5. [PMID: 38277055 DOI: 10.1007/s12029-023-00994-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2023] [Indexed: 01/27/2024]
Abstract
PURPOSE Despite advances in systemic therapy, outcomes of patients with gastric cancer (GC) peritoneal carcinomatosis (PC) remain poor, in part because of poor penetrance of systemic therapy into peritoneal metastasis due to the plasma-peritoneal barrier and anarchic intra-tumoral circulation. Hence, regional treatment approach with administration of chemotherapy directly into the peritoneal cavity (intraperitoneal, IP) under various conditions, combined with or without cytoreductive surgery (CRS) has remained an area of significant research interest. The purpose of this review is to provide high-level evidence for regional treatment approaches in the management of GCPC with limited peritoneal disease. METHODS A review of the current literature and ongoing clinical trials for regional IP therapies for GCPC was performed. Studies included in this review comprise of phase III randomized controlled trials, non-randomized phase II studies, high-impact retrospective studies, and active ongoing clinical trials for each available IP modality. RESULTS The three common IP approaches are heated intraperitoneal chemotherapy (HIPEC), normothermic intraperitoneal chemotherapy (NIPEC) and more recently introduced, pressurized intraperitoneal aerosolized chemotherapy (PIPAC). These IP approaches have been combined with systemic therapy and/or CRS with varying degrees of promising results, demonstrating evidence of improvements in survival rates and peritoneal disease control. Patient selection, optimization of systemic therapy, and completeness of cytoreduction have emerged as major factors influencing the design of contemporary and ongoing trials. CONCLUSION IP chemotherapy has a clear role in the management of patients with GCPC, and when combined with CRS in appropriately selected patients has the potential to significantly improve survival. Ongoing and upcoming IP therapy clinical trials hold great promise to shape the treatment paradigm for GCPC.
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Affiliation(s)
- Amy Y Li
- Department of Surgery, University of California, Irvine, 3800 Chapman Ave, Ste 7400, 92868, Orange, CA, USA
| | - Shaina Sedighim
- Department of Surgery, University of California, Irvine, 3800 Chapman Ave, Ste 7400, 92868, Orange, CA, USA
| | - Fatemeh Tajik
- Department of Surgery, University of California, Irvine, 3800 Chapman Ave, Ste 7400, 92868, Orange, CA, USA
| | - Aaqil M Khan
- Department of Surgery, University of California, Irvine, 3800 Chapman Ave, Ste 7400, 92868, Orange, CA, USA
| | - Vinodh K Radhakrishnan
- Department of Surgery, University of California, Irvine, 3800 Chapman Ave, Ste 7400, 92868, Orange, CA, USA
| | - Farshid Dayyani
- Department of Medicine, University of California, Irvine, Orange, USA
| | - Maheswari Senthil
- Department of Surgery, University of California, Irvine, 3800 Chapman Ave, Ste 7400, 92868, Orange, CA, USA.
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13
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Verbeek JGE, van der Sluis K, Vollebergh MA, van Sandick JW, van Harten WH, Retèl VP. Early Cost-Effectiveness Analysis of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Gastric Cancer Patients with Limited Peritoneal Carcinomatosis. PHARMACOECONOMICS - OPEN 2024; 8:119-131. [PMID: 38032438 PMCID: PMC10781926 DOI: 10.1007/s41669-023-00454-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/06/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Gastric cancer patients with peritoneal carcinomatosis (PC) have a poor prognosis, with a median overall survival of 10 months when treated with systemic chemotherapy only. Cohort studies showed that cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) might improve the prognosis for gastric cancer patients with limited PC. Besides generating trial data on clinical effectiveness, it is crucial to timely collect information on economic aspects to guide the reimbursement decision-making process. No previous data have been published on the cost(-effectiveness) of CRS/HIPEC in this group of patients. Therefore, we performed an early model-based cost-effectiveness analysis of CRS/HIPEC for gastric cancer patients with limited PC in the Dutch setting. METHODS We constructed a two-state (alive-dead) Markov transition model to evaluate costs and clinical outcomes from a Dutch healthcare perspective. Clinical outcomes, transition probabilities and utilities were derived from literature and verified by clinical experts in the field. Costs were measured using two available representative cohorts (2010-2017): one 'systemic chemotherapy only' cohort and one 'CRS/HIPEC' cohort (n = 10 each). Incremental cost-utility ratios (ICURs) were expressed as Euros per quality-adjusted life-year (QALY). We performed probabilistic and deterministic sensitivity, scenario, and value-of-information analyses using a willingness-to-pay (WTP) threshold of €80,000/QALY, which reflects the Dutch norm for severe diseases. RESULTS In the base-case analysis, CRS/HIPEC yielded more QALYs (increment of 0.68) and more costs (increment of €34,706) compared with systemic chemotherapy only, resulting in an ICUR of €50,990/QALY. The probability that CRS/HIPEC was cost effective compared with systemic chemotherapy alone was 64%. To reduce uncertainty, the expected value of perfect information amounted to €4,021,468. The scenario analyses did not alter the results and showed that treatment costs, lifetime health-related quality of life and overall survival had the largest influence on the model. CONCLUSIONS The presented early cost-effectiveness analysis suggests that adding CRS/HIPEC to systemic chemotherapy for gastric cancer patients with limited PC has a good chance of being cost-effectiveness compared with systemic chemotherapy alone when using a WTP of €80,000/QALY. However, there is substantial uncertainty in view of the current available data on effectiveness. Results from the ongoing phase III PERISCOPE II trial are therefore crucial for further decisions on treatment policy and its cost-effectiveness.
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Affiliation(s)
- Joost G E Verbeek
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, P.O. Box 90203, 1006 BE, Amsterdam, The Netherlands
- Department of Health Technology and Services Research, University of Twente, Enschede, The Netherlands
| | - Karen van der Sluis
- Department of Surgery, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Marieke A Vollebergh
- Department of Gastrointestinal Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Wim H van Harten
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, P.O. Box 90203, 1006 BE, Amsterdam, The Netherlands
- Department of Health Technology and Services Research, University of Twente, Enschede, The Netherlands
| | - Valesca P Retèl
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, P.O. Box 90203, 1006 BE, Amsterdam, The Netherlands.
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
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Sarvestani AL, Gregory SN, Akmal SR, Hernandez JM, van der Sluis K, van Sandick JW. Gastrectomy + Cytoreductive Surgery + HIPEC for Gastric Cancer with Peritoneal Dissemination (PERISCOPE II). Ann Surg Oncol 2024; 31:28-30. [PMID: 37947975 DOI: 10.1245/s10434-023-14415-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/25/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Amber Leila Sarvestani
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Stephanie N Gregory
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Sarfraz R Akmal
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jonathan M Hernandez
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.
| | - Karen van der Sluis
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - Johanna W van Sandick
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
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Kobiałka S, Sędłak K, Pelc Z, Mlak R, Endo Y, Bogacz P, Kurylcio A, Polkowski WP, Pawlik TM, Rawicz-Pruszyński K. Hyperthermic Intraperitoneal Chemotherapy (HIPEC), Oncological Outcomes and Long-Term Survival among Patients with Gastric Cancer and Limited Peritoneal Disease Progression after Neoadjuvant Chemotherapy. J Clin Med 2023; 13:161. [PMID: 38202168 PMCID: PMC10779559 DOI: 10.3390/jcm13010161] [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: 11/30/2023] [Revised: 12/22/2023] [Accepted: 12/26/2023] [Indexed: 01/12/2024] Open
Abstract
INTRODUCTION The role of surgery in stage IV gastric cancer with peritoneal metastasis (PM) remains unclear. The objective of the current single-center study was to define the impact of gastrectomy with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) on outcomes among Central European GC patients with limited peritoneal disease progression after neoadjuvant chemotherapy (NAC). METHODS Patients with histologically confirmed GC who underwent curative-intent multimodal treatment between 2013 and 2023 were included. Patients without adenocarcinoma, who did not undergo gastrectomy, had early (cT1) or metastatic GC at the time of initial diagnosis, who underwent multivisceral resection, incomplete cytoreduction or palliative care, died before planned curative-intent treatment, or had incomplete clinical or pathological missing information were excluded. RESULTS A total of 74 patients who underwent curative-intent treatment for GC with PM were included in the final analytic cohort. Patients who underwent gastrectomy with CRS+HIPEC were less likely to achieve TOO (CRS+HIPEC: 28% vs. CRS: 57.1%, p = 0.033) compared with individuals after CRS alone. Specifically, patients who underwent gastrectomy with CRS+HIPEC had a higher likelihood of postoperative complications (CRS+HIPEC: 48% vs. CRS: 20.4%, p = 0.018) and longer hospital LOS (median, CRS+HIPEC: 12 vs. CRS: 10, p = 0.019). While administration of HIPEC did not impact long-term survival (median OS, CRS+HIPEC: 16 months vs. CRS: 12 months, p = 0.55), postoperative complications (median OS, CCI < 30:16 months vs. CCI > 30:5 months, p = 0.024) and ICU stay (median OS, no ICU stay: 16 months vs. ICU stay: 5 months, p = 0.008) were associated with worsened long-term survival among GC patients with PM. CONCLUSIONS Data from the current study demonstrated a lack of survival benefit among advanced GC patients with PM undergoing gastrectomy with CRS+HIPEC when compared with individuals after gastrectomy with CRS alone. Administration of perioperative chemotherapy and achievement of TO failed to withstand the peritoneal disease progression during NAC.
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Affiliation(s)
- Sebastian Kobiałka
- Department of Surgical Oncology, Medical University of Lublin, 20-080 Lublin, Poland; (S.K.); (K.S.); (Z.P.); (A.K.); (W.P.P.)
| | - Katarzyna Sędłak
- Department of Surgical Oncology, Medical University of Lublin, 20-080 Lublin, Poland; (S.K.); (K.S.); (Z.P.); (A.K.); (W.P.P.)
| | - Zuzanna Pelc
- Department of Surgical Oncology, Medical University of Lublin, 20-080 Lublin, Poland; (S.K.); (K.S.); (Z.P.); (A.K.); (W.P.P.)
| | - Radosław Mlak
- Department of Laboratory Diagnostics, Medical University of Lublin, 20-080 Lublin, Poland;
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH 43210, USA; (Y.E.); (T.M.P.)
| | - Paweł Bogacz
- Department of Surgical Oncology, Medical University of Lublin, 20-080 Lublin, Poland; (S.K.); (K.S.); (Z.P.); (A.K.); (W.P.P.)
| | - Andrzej Kurylcio
- Department of Surgical Oncology, Medical University of Lublin, 20-080 Lublin, Poland; (S.K.); (K.S.); (Z.P.); (A.K.); (W.P.P.)
| | - Wojciech P. Polkowski
- Department of Surgical Oncology, Medical University of Lublin, 20-080 Lublin, Poland; (S.K.); (K.S.); (Z.P.); (A.K.); (W.P.P.)
| | - Timothy M. Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH 43210, USA; (Y.E.); (T.M.P.)
| | - Karol Rawicz-Pruszyński
- Department of Surgical Oncology, Medical University of Lublin, 20-080 Lublin, Poland; (S.K.); (K.S.); (Z.P.); (A.K.); (W.P.P.)
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH 43210, USA; (Y.E.); (T.M.P.)
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16
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Djadou TM, Poh KS, Yellinek S, Fayazzadeh H, El-Hayek K, Simpfendorfer CH, DaSilva G, Wexner SD. Cytoreductive Surgery and Hyperthermic Peritoneal Chemotherapy in Appendiceal and Colorectal Cancer: Outcomes and Survival. Am Surg 2023; 89:5757-5767. [PMID: 37155318 DOI: 10.1177/00031348231175452] [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] [Indexed: 05/10/2023]
Abstract
BACKGROUND We reviewed outcomes following cytoreductive surgery/hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with appendiceal or colorectal neoplasms and evaluated key prognostic indicators for treatment. METHODS All patients who underwent cytoreductive surgery/HIPEC for appendiceal and colorectal neoplasms were identified from an IRB-approved database. Patient demographics, operative reports, and postoperative outcomes were reviewed. RESULTS 110 patients [median age 54.5 (18-79) years, 55% male] were included. Primary tumor location was colorectal (58; 52.7%) and appendiceal (52; 47.3%). 28.2%, .9%, and 12.7% had right, left, and sigmoid tumors, respectively; 11.8% had rectal tumors. 12/13 rectal cancer patients underwent preoperative radiotherapy. Mean Peritoneal Cancer Index was 9.6 ± 7.7; complete cytoreduction was achieved in 90.9%. 53.6% developed postoperative complications. Reoperation, perioperative mortality, and 30-day readmission rates were 1.8%, .09%, and 13.6%, respectively. Recurrence at a median of 11.1 months was 48.2%; overall survival at 1 and 2 years was 84% and 56.8%, respectively; disease-free survival was 60.8% and 33.7%, respectively, at a median follow-up of 16.8 (0-86.8) months. Univariate analysis of preoperative chemotherapy, primary malignancy location, primary tumor perforated or obstructive, postoperative bleeding complication, and pathology of adenocarcinoma, mucinous adenocarcinoma and negative lymph nodes were identified as possible predictive factors of survival. Multivariate logistic regression analysis showed that preoperative chemotherapy (P < .001), perforated tumor (P = .003), and postoperative intra-abdominal bleeding (P < .001) were independent prognostic indicators for survival. CONCLUSIONS Cytoreductive surgery/HIPEC for colorectal and appendiceal neoplasms has low mortality and high completeness of cytoreduction score. Preoperative chemotherapy, primary tumor perforation, and postoperative bleeding are adverse risk factors for survival.
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Affiliation(s)
- Teresa Moreno Djadou
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
- Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Keat Seong Poh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Shlomo Yellinek
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
| | | | - Kevin El-Hayek
- Division of Surgical Oncology, Division of General Surgery, MetroHealth System, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH and Northeast Ohio Medical University, Rootstown, OH
| | | | - Giovanna DaSilva
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
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Jain AJ, Badgwell BD. Current Evidence for the Use of HIPEC and Cytoreductive Surgery in Gastric Cancer Metastatic to the Peritoneum. J Clin Med 2023; 12:6527. [PMID: 37892663 PMCID: PMC10607605 DOI: 10.3390/jcm12206527] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/11/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
Gastric cancer (GCa) is an aggressive malignancy, representing the third leading cause of cancer mortality worldwide. The poor prognosis of GCa can be associated with the prevalence of peritoneal metastasis (PM). Current international and national GCa treatment guidelines only recommend palliative treatment options for patients with PM. Since the 1980s there have been multiple single arm trials, randomized controlled trials, and metanalysis investigating the use of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with advanced GCa, with or without PM. Results from these studies have been encouraging, with some large-volume centers even incorporating HIPEC into their treatment algorithms for patients with advanced GCa. Additionally, there are several ongoing trials that, when completed, will increase our understanding of the efficacy of CRS & HIPEC in patients with GCa metastatic to the peritoneum. Herein we review the current evidence, ongoing trials, consensus guidelines, and future considerations regarding the use of CRS & HIPEC in patients suffering from GCa with PM.
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Affiliation(s)
- Anish J. Jain
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Brian D. Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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18
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Ramos MFKP, Pereira MA, Charruf AZ, Victor CR, Gregorio JVAM, Alban LBV, Moniz CMV, Zilberstein B, Mello ESD, Hoff PMG, Ribeiro Junior U, Dias AR. INTRAPERITONEAL CHEMOTHERAPY FOR GASTRIC CANCER WITH PERITONEAL CARCINOMATOSIS: STUDY PROTOCOL OF A PHASE II TRIAL. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2023; 36:e1744. [PMID: 37466566 PMCID: PMC10356002 DOI: 10.1590/0102-672020230026e1744] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 04/26/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Peritoneal carcinomatosis in gastric cancer is considered a fatal disease, without expectation of definitive cure. As systemic chemotherapy is not sufficient to contain the disease, a multimodal approach associating intraperitoneal chemotherapy with surgery may represent an alternative for these cases. AIMS The aim of this study was to investigate the role of intraperitoneal chemotherapy in stage IV gastric cancer patients with peritoneal metastasis. METHODS This study is a single institutional single-arm prospective clinical trial phase II (NCT05541146). Patients with the following inclusion criteria undergo implantation of a peritoneal catheter for intraperitoneal chemotherapy: Stage IV gastric adenocarcinoma; age 18-75 years; Peritoneal carcinomatosis with peritoneal cancer index<12; Eastern Cooperative Oncology Group 0/1; good clinical status; and lab exams within normal limits. The study protocol consists of four cycles of intraperitoneal chemotherapy with paclitaxel associated with systemic chemotherapy. After treatment, patients with peritoneal response assessed by staging laparoscopy undergo conversion gastrectomy. RESULTS The primary outcome is the rate of complete peritoneal response. Progression-free and overall survivals are other outcomes evaluated. The study started in July 2022, and patients will be screened for inclusion until 30 are enrolled. CONCLUSIONS Therapies for advanced gastric cancer patients have been evaluated in clinical trials but without success in patients with peritoneal metastasis. The treatment proposed in this trial can be promising, with easy catheter implantation and ambulatory intraperitoneal chemotherapy regime. Verifying the efficacy and safety of paclitaxel with systemic chemotherapy is an important progress that this study intends to investigate.
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Affiliation(s)
| | - Marina Alessandra Pereira
- Universidade de São Paulo, Cancer Institute, Faculty of Medicine, Department of Gastroenterology - São Paulo (SP), Brazil
| | - Amir Zeide Charruf
- Universidade de São Paulo, Cancer Institute, Faculty of Medicine, Department of Gastroenterology - São Paulo (SP), Brazil
| | - Carolina Ribeiro Victor
- Universidade de São Paulo, Cancer Institute, Faculty of Medicine, Department of Radiology and Oncology - São Paulo (SP), Brazil
| | | | - Luciana Bastos Valente Alban
- Universidade de São Paulo, Cancer Institute, Faculty of Medicine, Department of Radiology and Oncology - São Paulo (SP), Brazil
| | - Camila Motta Venchiarutti Moniz
- Universidade de São Paulo, Cancer Institute, Faculty of Medicine, Department of Radiology and Oncology - São Paulo (SP), Brazil
| | - Bruno Zilberstein
- Universidade de São Paulo, Cancer Institute, Faculty of Medicine, Department of Gastroenterology - São Paulo (SP), Brazil
| | - Evandro Sobroza de Mello
- Universidade de São Paulo, Cancer Institute, Faculty of Medicine, Department of Pathology - São Paulo (SP), Brazil
| | - Paulo Marcelo Gehm Hoff
- Universidade de São Paulo, Cancer Institute, Faculty of Medicine, Department of Radiology and Oncology - São Paulo (SP), Brazil
| | - Ulysses Ribeiro Junior
- Universidade de São Paulo, Cancer Institute, Faculty of Medicine, Department of Gastroenterology - São Paulo (SP), Brazil
| | - Andre Roncon Dias
- Universidade de São Paulo, Cancer Institute, Faculty of Medicine, Department of Gastroenterology - São Paulo (SP), Brazil
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Sammartino P, De Manzoni G, Marano L, Marrelli D, Biacchi D, Sommariva A, Scaringi S, Federici O, Guaglio M, Angrisani M, Cardi M, Fassari A, Casella F, Graziosi L, Roviello F. Gastric Cancer (GC) with Peritoneal Metastases (PMs): An Overview of Italian PSM Oncoteam Evidence and Study Purposes. Cancers (Basel) 2023; 15:3137. [PMID: 37370747 DOI: 10.3390/cancers15123137] [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: 03/01/2023] [Revised: 04/30/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
Gastric cancer (GC) continues to be one of the leading types of malignancies worldwide, despite an ongoing decrease in incidence. It is the fifth most frequent type of cancer in the world and the fourth leading cause of cancer death. Peritoneal metastases (PMs) occur in 20-30% of cases during the natural history of the disease. Systemic chemotherapy (SC) is undoubtedly the standard of care for patients with GC and PMs. However, with the development of highly effective regimens (SC combined with intraperitoneal chemotherapy), significant tumor shrinkage has been observed in many patients with synchronous GC and PMs, allowing some to undergo curative resection "conversion surgery" with long-term survival. In recent years, there has been growing interest in intraperitoneal chemotherapy for PMs, because the reduced drug clearance associated with the peritoneal/plasma barrier allows for direct and prolonged drug exposure with less systemic toxicity. These procedures, along with other methods used for peritoneal surface malignancies (PSMs), can be used in GCs with PMs as neoadjuvant chemotherapy or adjuvant treatments after radical surgery or as palliative treatments delivered either laparoscopically or-more recently-as pressurized intraperitoneal aerosol chemotherapy. The great heterogeneity of patients with stage IV gastric cancer did not allow us to carry out a systemic review; therefore, we limited ourselves to providing readers with an overview to clarify the indications and outcomes of integrated treatments for GCs with PMs by analyzing reports from the international clinical literature and the specific experiences of our oncoteam.
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Affiliation(s)
- Paolo Sammartino
- CRS and HIPEC Unit, Pietro Valdoni, Umberto I Policlinico di Roma, 00161 Roma, Italy
| | | | - Luigi Marano
- Department of Medicine, Surgery, and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, 53100 Siena, Italy
| | - Daniele Marrelli
- Department of Medicine, Surgery, and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, 53100 Siena, Italy
| | - Daniele Biacchi
- CRS and HIPEC Unit, Pietro Valdoni, Umberto I Policlinico di Roma, 00161 Roma, Italy
| | - Antonio Sommariva
- Advanced Surgical Oncology Unit, Surgical Oncology of the Esophagus and Digestive Tract, Veneto, Institute of Oncology IOV-IRCCS, 35128 Padova, Italy
| | - Stefano Scaringi
- AOU Careggi, IBD Unit-Chirurgia dell'Apparato Digerente, 50100 Firenze, Italy
| | - Orietta Federici
- Peritoneal Tumors Unit, IRCCS Regina Elena National Cancer Institute, 00144 Rome, Italy
| | - Marcello Guaglio
- Peritoneal Surface Malignancies Unit, Fondazione Istituto Nazionale Tumori IRCCS Milano, 20133 Milano, Italy
| | - Marco Angrisani
- CRS and HIPEC Unit, Pietro Valdoni, Umberto I Policlinico di Roma, 00161 Roma, Italy
| | - Maurizio Cardi
- CRS and HIPEC Unit, Pietro Valdoni, Umberto I Policlinico di Roma, 00161 Roma, Italy
| | - Alessia Fassari
- CRS and HIPEC Unit, Pietro Valdoni, Umberto I Policlinico di Roma, 00161 Roma, Italy
| | - Francesco Casella
- Upper GI Surgery Division, University of Verona, 37129 Verona, Italy
| | - Luigina Graziosi
- General and Emergency Surgery Department, Santa Maria Della Misericordia Hospital, University of Perugia, 06125 Perugia, Italy
| | - Franco Roviello
- Department of Medicine, Surgery, and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, 53100 Siena, Italy
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20
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Chidambaram S, Guiral DC, Markar SR. Novel Multi-Modal Therapies and Their Prognostic Potential in Gastric Cancer. Cancers (Basel) 2023; 15:3113. [PMID: 37370723 DOI: 10.3390/cancers15123113] [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: 03/18/2023] [Revised: 05/22/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Gastric cancer has a poor prognosis and involves metastasis to the peritoneum in over 40% of patients. The optimal treatment modalities have not been established for gastric cancer patients with peritoneal carcinomatosis (GC/PC). Although studies have reported favourable prognostic factors, these have yet to be incorporated into treatment guidelines. Hence, our review aims to appraise the latest diagnostic and treatment developments in managing GC/PC. METHODS A systematic review of the literature was performed using MEDLINE, EMBASE, the Cochrane Review, and Scopus databases. Articles were evaluated for the use of hyperthermic intraperitoneal chemotherapy (HIPEC) and pressurised intraperitoneal aerosolised chemotherapy (PIPAC) in GC/PC. A meta-analysis of studies reporting on overall survival (OS) in HIPEC and comparing the extent of cytoreduction as a prognostic factor was also carried out. RESULTS The database search yielded a total of 2297 studies. Seventeen studies were included in the qualitative and quantitative analyses. Eight studies reported the short-term OS at 1 year as the primary outcome measure, and our analysis showed a significantly higher OS for the HIPEC/CRS cohort compared to the CRS cohort (pooled OR = 0.53; p = 0.0005). This effect persisted longer term at five years as well (pooled OR = 0.52; p < 0.0001). HIPEC and CRS also showed a longer median OS compared to CRS (pooled SMD = 0.61; p < 0.00001). Three studies reporting on PIPAC demonstrated a pooled OS of 10.3 (2.2) months. Prognostic factors for longer OS include a more complete cytoreduction (pooled OR = 5.35; p < 0.00001), which correlated with a peritoneal carcinomatosis index below 7. CONCLUSIONS Novel treatment strategies, such as HIPEC and PIPAC, are promising in the management of GC/PC. Further work is necessary to define their role within the treatment algorithm and identify relevant prognostic factors that will assist patient selection.
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Affiliation(s)
| | - Delia Cortés Guiral
- Surgical Oncology and General Surgery Department, King Khaled Hospital, Najran 66262, Saudi Arabia
| | - Sheraz Rehan Markar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 17176 Stockholm, Sweden
- Nuffield Department of Surgery, University of Oxford, Oxford OX3 9DU, UK
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Zhang J, Sun Y, Bai X, Wang P, Tian L, Tian Y, Zhong Y. Single versus multiple hyperthermic intraperitoneal chemotherapy applications for T4 gastric cancer patients: Efficacy and safety profiles. Front Oncol 2023; 13:1109633. [PMID: 37007142 PMCID: PMC10063781 DOI: 10.3389/fonc.2023.1109633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/06/2023] [Indexed: 03/19/2023] Open
Abstract
ObjectiveTo explore the clinical safety and efficacy of single and multiple applications of lobaplatin-based hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with T4 gastric cancer and to evaluate the impact of HIPEC on peritoneal metastasis.Materials and methodsWe retrospectively reviewed prospectively collected data from T4 gastric cancer patients who underwent radical gastric resection plus HIPEC between March 2018 and August 2020 from the National Cancer Center and Huangxing Cancer Hospital. Patients who underwent radical surgery and HIPEC were divided into two groups: the single-HIPEC group (radical resection + a single application of intraoperative HIPEC with lobaplatin 50 mg/m2 at 43.0 ± 0.5°C for 60 min), and a multi-HIPEC group (two more HIPEC applications were performed after radical surgery).ResultsA total of 78 patients were enrolled in this two-center study; among them, 40 patients were in the single-HIPEC group, and 38 patients were in the multi-HIPEC group. The baseline characteristics were well balanced between the two groups. There was no significant difference in the postoperative complication rates between the two groups (P > 0.05). Mild renal dysfunction, mild liver dysfunction, low platelet levels and low white blood cell levels were recorded in both groups, without significant differences between the two groups (P > 0.05). After a mean follow-up of 36.8 months, 3 (7.5%) patients in the single-HIPEC group and 2 (5.2%) patients in the multi-HIPEC group experienced peritoneal recurrence (P > 0.05). Both groups had comparable 3-year overall survival (OS) (51.3% vs. 54.5%, P = 0.558) and 3-year disease-free survival (DFS) rates (44.1% vs. 45.7%, P = 0.975). Multivariate analysis showed that an age > 60 years and low preoperative albumin levels were independent risk factors for postoperative complications.ConclusionSingle and multiple applications of HIPEC in patients with T4 gastric cancer were safe and feasible. Both groups had similar postoperative complication rates, 3-year OS rates and 3-year DFS rates. Special attention should be given to HIPEC for patients aged > 60 years and patients with low preoperative albumin levels.
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Affiliation(s)
- Jing Zhang
- Department of Surgery, Huanxing Cancer Hospital, Beijing, China
| | - Yuemin Sun
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaofeng Bai
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Peng Wang
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liang Tian
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yantao Tian
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Yantao Tian, ; Yuxin Zhong,
| | - Yuxin Zhong
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Yantao Tian, ; Yuxin Zhong,
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22
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Senthil M, Dayyani F. Phase II clinical trial of sequential treatment with systemic chemotherapy and intraperitoneal paclitaxel for gastric and gastroesophageal junction peritoneal carcinomatosis - STOPGAP trial. BMC Cancer 2023; 23:209. [PMID: 36870941 PMCID: PMC9985848 DOI: 10.1186/s12885-023-10680-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND Studies from Asia indicate that normothermic intraperitoneal chemotherapy (NIPEC) may confer survival benefit in patients with gastric peritoneal carcinomatosis (PC). However, data regarding this approach is lacking in western population. The current STOPGAP trial is intended to assess 1-year progression-free survival benefit of sequential systemic chemotherapy and paclitaxel NIPEC in patients with gastric/ gastroesophageal junction (GEJ) adenocarcinoma PC. METHODS This is a prospective, single center, single arm, phase II investigator-initiated clinical trial. Patients with histologically proven gastric/GEJ (Siewert 3) adenocarcinoma with positive peritoneal cytology or PC will be eligible to participate after three months of standard of care systemic chemotherapy and with no evidence of visceral metastasis on restaging scans. The primary treatment is iterative paclitaxel NIPEC with systemic paclitaxel and 5-fluorouracil, which will be administered on days1 and 8 and repeated every three weeks for 4 cycles. Patients will undergo diagnostic laparoscopy both before and after NIPEC to assess peritoneal cancer index (PCI). Patients with PCI less than or equal to 10 in whom complete cytoreduction (CRS) is feasible may opt to undergo CRS with heated intraperitoneal chemotherapy (HIPEC). The primary endpoint is 1-year progression free survival and secondary endpoints are overall survival and patient reported quality of life outcomes measured by EuroQol- 5 dimensions-5 level (EuroQol-5D-5L) questionnaire. DISCUSSION If the sequential approach of systemic chemotherapy followed by paclitaxel NIPEC proves beneficial, then this approach could be used in larger, muti-institutional randomized clinical trial of gastric PC. TRIAL REGISTRATION The trial was registered on 21/02/2021, under clinical trials.gov; Identifier: NCT04762953.
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Affiliation(s)
- Maheswari Senthil
- Division of Surgical Oncology, University of California Irvine, 3800 Chapman Ave, Ste 6400, CA, 92868, Orange, USA.
| | - Farshid Dayyani
- Division of Hematology Oncology, University of California Irvine, CA, Orange, USA
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23
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Magyar CTJ, Rai A, Aigner KR, Jamadar P, Tsui TY, Gloor B, Basu S, Vashist YK. Current standards of surgical management of gastric cancer: an appraisal. Langenbecks Arch Surg 2023; 408:78. [PMID: 36745231 DOI: 10.1007/s00423-023-02789-5] [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: 05/27/2022] [Accepted: 12/02/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE Gastric cancer (GC) is the fifth most common malignancy worldwide and portends a grim prognosis due to a lack of appreciable improvement in 5-year survival. We aimed to analyze the available literature and summarize the current standards of surgical care for curative and palliative intent treatment of GC. METHODS We conducted a systematic search on the PubMed database for studies on the management of GC. RESULTS Endoscopic resection is an acceptable treatment option for T1a tumors. The role of optimal resection margin for GC remains unclear. D2 lymph node dissection remains the standard of care with splenectomy needed selectively for splenic hilum involvement. A distal pancreatic resection should be avoided. The advantage of bursectomy and omentectomy in GC surgery is not clear. Multi-visceral resection may be considered for locally advanced GC in carefully selected patients. Minimally invasive approaches are non-inferior to open surgery. Surgery should be abandoned prior even in metastatic GC within the frame of multimodal therapy approach. CONCLUSION Various trials have conclusively shown improved patient outcomes when well-established surgical standards are followed.
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Affiliation(s)
- Christian T J Magyar
- Department of Visceral Surgery and Medicine, Inselspital, University of Bern, Bern, Switzerland
| | - Ankit Rai
- Department of Surgery, All India Institute of Medical Sciences, Rishikesh, India
| | - Karl R Aigner
- Department of Surgical Oncology, Medias Klinikum, Burghausen, Germany
| | | | - Tung Y Tsui
- Department of Surgery, Asklepios Harzklinik, Goslar, Germany
| | - Beat Gloor
- Department of Visceral Surgery and Medicine, Inselspital, University of Bern, Bern, Switzerland
| | - Somprakas Basu
- Department of Surgery, All India Institute of Medical Sciences, Rishikesh, India
| | - Yogesh K Vashist
- Department of Surgery, All India Institute of Medical Sciences, Rishikesh, India.
- Department of Surgical Oncology, Medias Klinikum, Burghausen, Germany.
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Surgical Options for Peritoneal Surface Metastases from Digestive Malignancies-A Comprehensive Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020255. [PMID: 36837456 PMCID: PMC9960111 DOI: 10.3390/medicina59020255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/25/2023] [Accepted: 01/25/2023] [Indexed: 01/31/2023]
Abstract
The peritoneum is a common site for the dissemination of digestive malignancies, particularly gastric, colorectal, appendix, or pancreatic cancer. Other tumors such as cholangiocarcinomas, digestive neuroendocrine tumors, or gastrointestinal stromal tumors (GIST) may also associate with peritoneal surface metastases (PSM). Peritoneal dissemination is proven to worsen the prognosis of these patients. Cytoreductive surgery (CRS), along with systemic chemotherapy, have been shown to constitute a survival benefit in selected patients with PSM. Furthermore, the association of CRS with hyperthermic intraperitoneal chemotherapy (HIPEC) seems to significantly improve the prognosis of patients with certain types of digestive malignancies associated with PSM. However, the benefit of CRS with HIPEC is still controversial, especially due to the significant morbidity associated with this procedure. According to the results of the PRODIGE 7 trial, CRS for PSM from colorectal cancer (CRC) achieved overall survival (OS) rates higher than 40 months, but the addition of oxaliplatin-based HIPEC failed to improve the long-term outcomes. Furthermore, the PROPHYLOCHIP and COLOPEC trials failed to demonstrate the effectiveness of oxaliplatin-based HIPEC for preventing peritoneal metastases development in high-risk patients operated for CRC. In this review, we discuss the limitations of these studies and the reasons why these results are not sufficient to refute this technique, until future well-designed trials evaluate the impact of different HIPEC regimens. In contrast, in pseudomyxoma peritonei, CRS plus HIPEC represents the gold standard therapy, which is able to achieve 10-year OS rates ranging between 70 and 80%. For patients with PSM from gastric carcinoma, CRS plus HIPEC achieved median OS rates higher than 40 months after complete cytoreduction in patients with a peritoneal cancer index (PCI) ≤6. However, the data have not yet been validated in randomized clinical trials. In this review, we discuss the controversies regarding the most efficient drugs that should be used for HIPEC and the duration of the procedure. We also discuss the current evidence and controversies related to the benefit of CRS (and HIPEC) in patients with PSM from other digestive malignancies. Although it is a palliative treatment, pressurized intraperitoneal aerosolized chemotherapy (PIPAC) significantly increases OS in patients with unresectable PSM from gastric cancer and represents a promising approach for patients with PSM from other digestive cancers.
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25
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Zhong Y, Kang W, Hu H, Li W, Zhang J, Tian Y. Lobaplatin-based prophylactic hyperthermic intraperitoneal chemotherapy for T4 gastric cancer patients: A retrospective clinical study. Front Oncol 2023; 13:995618. [PMID: 36741012 PMCID: PMC9890050 DOI: 10.3389/fonc.2023.995618] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 01/03/2023] [Indexed: 01/19/2023] Open
Abstract
Objective To explore the clinical efficacy of lobaplatin-based prophylactic hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with T4 gastric cancer after surgery and to evaluate its impact on survival. Materials and methods Data on patients with T4 gastric cancer who underwent radical gastric resection between March 2016 and August 2017 were collected from the National Cancer Center and Huangxing Cancer Hospital. Enrolled patients were divided into two groups according to receiving or not receiving HIPEC. Results A total of 106 patients were included in this study; among them, 51 patients underwent radical gastric resection plus prophylactic HIPEC, and 55 patients underwent radical gastric resection only. The baseline characteristics were well balanced between the two groups. The postoperative platelet counts in the HIPEC group were significantly lower than those in the non-HIPEC group (P < 0.05); however, we did not observe any occurrences of serious bleeding in the HIPEC group. There were no significant differences in the postoperative complication rates between the two groups (P > 0.05). The postoperative (1 month) CEA, CA19-9, and CA72-4 levels in the HIPEC group were significantly decreased in the HIPEC group (P < 0.05). At a median follow-up of 59.3 months, 3 (5.5%) patients in the HIPEC group experienced peritoneal recurrence, and 10 (18.2%) patients in the non-HIPEC group experienced peritoneal recurrence (P < 0.05). Both groups had comparable 5-year overall survival (OS) rates (41.1% HIPEC group vs. 34.5% non-HIPEC group, P = 0.118). The 5-year disease-free survival was significantly higher in the HIPEC group than in the non-HIPEC group (28.6% versus 39.7%, p = 0.046). Conclusions Lobaplatin-based prophylactic HIPEC is feasible and safe for patients with T4 gastric cancer and does not increase postoperative adverse effects. The use of HIPEC showed a significant decrease in the incidence of local recurrence rates and blood tumor marker levels. The 5-year disease-free survival was significantly higher in the HIPEC group; however, the 5-year OS benefit was not found in T4 stage patients.
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Affiliation(s)
- Yuxin Zhong
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenzhe Kang
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Haitao Hu
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weikun Li
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Zhang
- Department of Surgery, Huanxing Cancer Hospital, Beijing, China,*Correspondence: Yantao Tian, ; Jing Zhang,
| | - Yantao Tian
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China,*Correspondence: Yantao Tian, ; Jing Zhang,
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26
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Siddiqi A, Johnston FM. The Perioperative and Operative Management of Esophageal and Gastric Cancer. Surg Oncol Clin N Am 2023; 32:65-81. [PMID: 36410922 DOI: 10.1016/j.soc.2022.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Optimal management of esophageal and gastric cancer during the perioperative period requires a coordinated multidisciplinary treatment effort. Accurate staging guides treatment strategy. Advances in minimally invasive surgery and endoscopy have reduced risks associated with resection while maintaining oncological standards. Although the standard perioperative chemo-and radiotherapy regimens have not yet been established, randomized control trials exploring this subject show promising results.
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Affiliation(s)
- Amn Siddiqi
- Department of Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Fabian M Johnston
- Division of Gastrointestinal Surgical Oncology, Johns Hopkins University, 600 North Wolfe Street, Baltimore, MD 21287, USA.
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Allievi N, Bianco F, Pisano M, Montori G, Fugazzola P, Coccolini F, Lotti M, Mosconi S, Merelli B, Campanati L, Lucianetti A, Ansaloni L, Magnone S. Hyperthermic intraperitoneal chemotherapy (HIPEC) as adjuvant and therapeutic options for patients with advanced gastric cancer at high risk of recurrence or established peritoneal metastases: a single-centre experience. Updates Surg 2023; 75:159-167. [PMID: 36371549 DOI: 10.1007/s13304-022-01399-y] [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: 03/31/2022] [Accepted: 10/04/2022] [Indexed: 11/13/2022]
Abstract
Peritoneal metastases from gastric cancer (PM-GC) have a detrimental prognostic impact on survival and there is a lack of consensus regarding treatment. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) may offer a chance for prolonged survival as compared to standard chemotherapy. This study aims to present our experience in the management of GC with CRS and HIPEC. This is a single-centre retrospective study. Patients were divided into two groups: patients with GC at high risk for developing PM-GC (adjuvant HIPEC group) and patients with PM-GC or positive peritoneal cytology (therapeutic CRS and HIPEC group). Overall survival (OS) and disease-free survival (DFS) were considered as outcome measures. A total of 41 patients with a GC primary received surgery and HIPEC: 14 patients (34.1%) were in the adjuvant HIPEC group, while 27 patients (65.9%) were in the therapeutic CRS and HIPEC group. In the adjuvant HIPEC group, the 1- and 3-year OS were 85.7% and 71.4%, while 1- and 3-year DFS were 71.4% and 64.3%, respectively. In the therapeutic CRS and HIPEC group, OS was 60.3% and 35.1% at 1 and 3 years, whereas 1- and 3-year DFS were 38% and 32.6%, respectively. Univariate survival analysis of patients in the therapeutic CRS and HIPEC group showed that the presence of lymph node metastasis and signet ring cell histology predicted worse OS, while PCI > 12 and lymph node metastasis were associated with decreased DFS. Treatment of highly selected patients with GC at high risk of peritoneal recurrence or established PM with CRS and HIPEC showed satisfactory results in terms of OS and DFS.
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Affiliation(s)
- Niccolò Allievi
- First Department of General Surgery, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127, Bergamo, Italy
| | - Federica Bianco
- First Department of General Surgery, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127, Bergamo, Italy
| | - Michele Pisano
- First Department of General Surgery, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127, Bergamo, Italy
| | | | - Paola Fugazzola
- Unit of General Surgery, IRCCS San Matteo Foundation Hospital, Pavia, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Marco Lotti
- Division of General Surgery, Fatebenefratelli Oftalmico Hospital, Milan, Italy
| | | | - Barbara Merelli
- Medical Oncology Unit, Giovanni XXIII Hospital, Bergamo, Italy
| | - Luca Campanati
- First Department of General Surgery, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127, Bergamo, Italy
| | - Alessandro Lucianetti
- First Department of General Surgery, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127, Bergamo, Italy
| | - Luca Ansaloni
- Unit of General Surgery, IRCCS San Matteo Foundation Hospital, Pavia, Italy
| | - Stefano Magnone
- First Department of General Surgery, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127, Bergamo, Italy.
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Goetze TO, Al-Batran SE. Perspectives on the Management of Oligometastatic Disease in Esophago-Gastric Cancer. Cancers (Basel) 2022; 14:5200. [PMID: 36358619 PMCID: PMC9658190 DOI: 10.3390/cancers14215200] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/17/2022] [Accepted: 10/21/2022] [Indexed: 09/22/2023] Open
Abstract
Gastric adenocarcinoma and esophageal cancer are the fifth and seventh most common cancer types worldwide. At the time of initial diagnosis, up to 50% of esophagogastric cancers present with distant metastatic lesions and are candidates for chemotherapy. Curative surgery in this stage is still an experimental approach. Only a small number of these metastatic patients show an oligometastatic disease with no uniform definition of what oligometastatic means in gastric cancer. Nevertheless, the question remains unanswered as to whether these patients are still candidates for curative concepts. Some studies have attempted to answer this question but have not been adequately designed to address the role of a curative-intended multimodal therapy in this setting. The current FLOT-5 is designed to potentially provide a definitive answer to the question of whether curatively intended surgery plays a role or is a disadvantage in this setting.
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Affiliation(s)
- Thorsten Oliver Goetze
- Krankenhaus Nordwest gGmbH, Institut of Clinical Cancer Research, UCT—University Cancer Center Frankfurt-Marburg, Steinbacher Hohl 2-26, 60488 Frankfurt, Germany
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29
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Drubay V, Nuytens F, Renaud F, Adenis A, Eveno C, Piessen G. Poorly cohesive cells gastric carcinoma including signet-ring cell cancer: Updated review of definition, classification and therapeutic management. World J Gastrointest Oncol 2022; 14:1406-1428. [PMID: 36160745 PMCID: PMC9412924 DOI: 10.4251/wjgo.v14.i8.1406] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 05/08/2022] [Accepted: 07/17/2022] [Indexed: 02/05/2023] Open
Abstract
While the incidence of gastric cancer (GC) in general has decreased worldwide in recent decades, the incidence of diffuse cancer historically comprising poorly cohesive cells-GC (PCC-GC) and including signet ring cell cancer is rising. Literature concerning PCC-GC is scarce and unclear, mostly due to a large variety of historically used definitions and classifications. Compared to other histological subtypes of GC, PCC-GC is nevertheless characterized by a distinct set of epidemiological, histological and clinical features which require a specific diagnostic and therapeutic approach. The aim of this review was to provide an update on the definition, classification and therapeutic strategies of PCC-GC. We focus on the updated histological definition of PCC-GC, along with its implications on future treatment strategies and study design. Also, specific considerations in the diagnostic management are discussed. Finally, the impact of some recent developments in the therapeutic management of GC in general such as the recently validated taxane-based regimens (5-Fluorouracil, leucovorin, oxaliplatin and docetaxel), the use of hyperthermic intraperitoneal chemotherapy as well as pressurized intraperitoneal aerosol chemotherapy and targeted therapy have been reviewed in depth for their relative importance for PCC-GC in particular.
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Affiliation(s)
- Vincent Drubay
- Department of Digestive and Oncological Surgery, University Lille, Claude Huriez University Hospital, Lille 59000, France
- Department of Digestive Surgery, Cambrai Hospital Center and Sainte Marie, Group of Hospitals of The Catholic Institute of Lille, Cambrai 59400, France
| | - Frederiek Nuytens
- Department of Digestive and Oncological Surgery, University Lille, Claude Huriez University Hospital, Lille 59000, France
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, AZ Groeninge Hospital, Kortrijk 8500, Belgium
| | - Florence Renaud
- Department of Pathology, University Lille Hospital, Lille 59000, France
- CNRS, Inserm, UMR9020-U1277-CANTHER-Cancer, University Lille, CHU Lille, Lille 59000, France
- FREGAT Network, Claude Huriez University Hospital, Lille 59000, France
| | - Antoine Adenis
- FREGAT Network, Claude Huriez University Hospital, Lille 59000, France
- Department of Medical Oncology, Montpellier Cancer Institute, Monpellier 34000, France
- IRCM, Inserm, University of Monpellier, Monpellier 34000, France
| | - Clarisse Eveno
- Department of Digestive and Oncological Surgery, University Lille, Claude Huriez University Hospital, Lille 59000, France
- CNRS, Inserm, UMR9020-U1277-CANTHER-Cancer, University Lille, CHU Lille, Lille 59000, France
- FREGAT Network, Claude Huriez University Hospital, Lille 59000, France
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, University Lille, Claude Huriez University Hospital, Lille 59000, France
- CNRS, Inserm, UMR9020-U1277-CANTHER-Cancer, University Lille, CHU Lille, Lille 59000, France
- FREGAT Network, Claude Huriez University Hospital, Lille 59000, France
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30
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Prabhu A, Mishra D, Brandl A, Yonemura Y. Gastric Cancer With Peritoneal Metastasis-A Comprehensive Review of Current Intraperitoneal Treatment Modalities. Front Oncol 2022; 12:864647. [PMID: 35719946 PMCID: PMC9204320 DOI: 10.3389/fonc.2022.864647] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 04/22/2022] [Indexed: 12/24/2022] Open
Abstract
The treatment of patients with peritoneal metastasis from gastric cancer continues to evolve. With various forms of intraperitoneal drug delivery available, it is now possible to reach the sites of peritoneal metastases, which were otherwise sub-optimally covered by systemic chemotherapy, owing to the blood peritoneal barrier. We conducted a narrative review based on an extensive literature research, highlighting the current available intraperitoneal treatment options, which resulted in improved survival in well-selected patients of peritoneally metastasized gastric cancer. Intraperitoneal chemotherapy showed promising results in four different treatment modalities: prophylactic, neoadjuvant, adjuvant, and palliative. It is now possible to choose the type of intraperitoneal treatment/s in combination with systemic treatment/s, depending on patients' general condition and peritoneal disease burden, thus providing individualized treatment to these patients. Randomized controlled trials for the different treatment modalities were mainly conducted in Asia and lack further validation in the other parts of the world. Most recent application tools, such as pressurized intraperitoneal aerosol chemotherapy, seem promising and need to pass the ongoing clinical trials.
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Affiliation(s)
- Aruna Prabhu
- Department of Surgical Oncology, Thangam Cancer Center, Namakkal, India
| | - Deepti Mishra
- Department of Surgical Oncology, Thangam Cancer Center, Namakkal, India
| | - Andreas Brandl
- Digestive Unit, Champalimaud Foundation, Lisbon, Portugal
- Department of Surgery, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Yutaka Yonemura
- Department of Regional Cancer therapy, Peritoneal Surface Malignancy Centee, Kishiwada Tokushukai Hospital, Kishiwada, Japan
- Japanese/Asian School of Peritoneal Surface Oncology, Osaka, Japan
- Department of Regional Cancer therapy, Peritoneal Surface Malignancy Center, Kusatsu General Hospital, Shiga, Japan
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Yin J, Che G, Wang W, Chen S, Liu J. Investigating the Prognostic Significance of Pyroptosis-Related Genes in Gastric Cancer and Their Impact on Cells' Biological Functions. Front Oncol 2022; 12:861284. [PMID: 35419279 PMCID: PMC8995648 DOI: 10.3389/fonc.2022.861284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/01/2022] [Indexed: 11/16/2022] Open
Abstract
Objective To probe into the role of pyroptosis-related genes in gastric cancer. Methods To establish pyroptosis-related genes, observe their expression in gastric cancer, and analyze the prognosis of pyroptosis-related genes in gastric cancer by single-factor COX, which showed that only GSDME had prognostic significance in gastric cancer. The mRNA expression profiles and lncRNA expression profiles of gastric cancer downloaded from the Cancer Genome Atlas were combined for weighted gene regulatory network analysis, after which the lncRNA nodes of the module to which GSDME belongs were extracted to obtain the lncRNAs−GSDME interactions, which were visualized with Cytoscape network plots. Finally, the effects of GSDME on the proliferation, migration, and apoptosis of gastric cancer cells were observed with CCK8, and flow cytometry. Results Our results show that only GSDME has prognostic significance in gastric cancer, and show that it has an important role in a variety of tumors. In addition, our results show that 16 lncRNAs have a significant interaction with GSDME. Finally, the experimental analysis showed that knocking down the expression level of GSDME could affect the growth as well as apoptosis of gastric cancer cells. Conclusion The significant prognostic significance of GSDME in gastric cancer and the fact that affecting GSDME expression inhibits gastric cancer cell growth suggest that GSDME can be used as a predictive biomarker.
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Affiliation(s)
- Jie Yin
- Department of Radiation Oncology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Gang Che
- Department of Surgical Oncology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wankun Wang
- Department of Surgical Oncology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shitu Chen
- Department of Surgical Oncology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jian Liu
- Department of Surgical Oncology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Noiret B, Piessen G, Eveno C. Update of randomized controlled trials evaluating cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in prevention and therapy of peritoneal metastasis: a systematic review. Pleura Peritoneum 2022; 7:51-61. [PMID: 35812007 PMCID: PMC9166620 DOI: 10.1515/pp-2021-0152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/18/2022] [Indexed: 11/15/2022] Open
Abstract
Abstract
Objectives
Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is associated with favorable short- and long-term oncological outcomes in highly selected patients with peritoneal metastasis (PM). The aim of our review was to review published, recruiting or ongoing randomized controlled trials (RCTs) evaluating CRS and HIPEC vs. other strategies (systemic chemotherapy or CRS alone) and to update the studies recently described in 2016.
Content
Systematic review according to PRISMA guidelines. Searches for published and ongoing trials were based, respectively, on PubMed and international clinical databases since 2016.
Summary
46 trials randomized 9,063 patients: 13 in colorectal cancer (3 in therapeutic strategy and 10 in prophylactic strategy), 16 in gastric cancer (4 in therapeutic strategy and 12 in prophylactic strategy) and 17 in ovarian cancer (12 in front-line therapy and 5 in recurrence settings).
Outlook
In contrast to many recruiting studies, few published studies analyzed the potential advantage of CRS and HIPEC in therapeutic and prophylactic treatment of PM. The potential effect of this combined treatment has been proven in ovarian cancer in interval surgery, but remains still debated in other situations. Promising trials are currently recruiting to provide further evidence of the effectiveness of CRS and HIPEC.
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Affiliation(s)
- Barbara Noiret
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital , Lille , France
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital , Lille , France
- UMR-S1277 - CANTHER laboratory “Cancer Heterogeneity, Plasticity and Resistance to Therapies” , Lille , France
| | - Clarisse Eveno
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital , Lille , France
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A population-based study on treatment and outcomes in patients with gastric adenocarcinoma diagnosed with distant interval metastases. Eur J Surg Oncol 2022; 48:1964-1971. [DOI: 10.1016/j.ejso.2022.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 02/06/2022] [Accepted: 03/04/2022] [Indexed: 12/20/2022] Open
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Harada K, Yamashita K, Iwatsuki M, Baba H, Ajani JA. Intraperitoneal therapy for gastric cancer peritoneal carcinomatosis. Expert Rev Clin Pharmacol 2022; 15:43-49. [PMID: 35184625 DOI: 10.1080/17512433.2022.2044790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
INTRODUCTION Gastric adenocarcinoma (GAC) is one of the most aggressive malignancies worldwide and has a poor prognosis. Multidisciplinary therapies are used in its treatment, but the prognosis for GAC patients with peritoneal metastases (PM) remains poor and there is no effective established approach. AREAS COVERED This review summarizes the results of recent clinical studies and recent advances in the management, including surgery, chemotherapy, targeted therapy, and immunotherapy. In this review, keywords were searched in combination with 'peritoneal carcinomatosis' and 'gastric cancer' in PubMed, and then studies that evaluated peritoneal carcinomatosis associated with gastric cancer were identified through reading them. Several studies were quoted at second hand. Despite recent advances in therapeutic approaches such as systemic chemotherapy, immunotherapy, intraperitoneal chemotherapy, debulking surgery, thermal hyperthermic intraperitoneal chemotherapy, pressurized intraperitoneal aerosol chemotherapy, immunotherapy, and best supportive therapy, further studies are necessary. This review also summarizes molecular biology of GAC patients with PM. EXPERT OPINION Each modality is advancing and some have shown therapeutic effects, but none have become standard treatments that exhibit remarkable effects. To improve the prognosis of GAC patients with PM, large-scale clinical trials and further basic research are required.
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Affiliation(s)
- Kazuto Harada
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Kohei Yamashita
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan.,Department of Gastrointestinal Medical Oncology, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Masaaki Iwatsuki
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
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Zhang JF, Lv L, Zhao S, Zhou Q, Jiang CG. Hyperthermic Intraperitoneal Chemotherapy (HIPEC) Combined with Surgery: A 12-Year Meta-Analysis of this Promising Treatment Strategy for Advanced Gastric Cancer at Different Stages. Ann Surg Oncol 2022; 29:3170-3186. [PMID: 35175455 DOI: 10.1245/s10434-021-11316-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/28/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND This meta-analysis was designed to systematically assess the effectiveness and safety of hyperthermic intraperitoneal chemotherapy (HIPEC) combined with surgery for different stages of advanced gastric cancer (AGC) during the last 12 years. METHODS The Cochrane Library, PubMed, Embase, Web of Science, and China National Knowledge Infrastructure (CNKI) were searched online, and papers were retrieved from other sources. Next, randomized controlled trials (RCTs) and high-quality nonrandomized controlled trials (NRCTs) were selected for this analysis. The meta-analysis was conducted with RevMan5.4 software. RESULT The 10 RCTs and 13 NRCTs selected for the study included 1892 patients. The overall survival rates were higher in the HIPEC group at 1 year (risk ratio [RR], 0.52; P = 0.004) and 3 years (RR, 0.63; P < 0.00001) than in the control group for the patients without peritoneal cancer, and the HIPEC group had a significant reduction in the recurrence rate (RR, 0.60; p < 0.00001). Among the patients with peritoneal carcinomatosis (PC), the HIPEC group had significantly higher overall survival rates at 1 year (RR, 0.62; P = 0.00001), 2 years (RR, 0.85; P = 0.002), and 3 years (RR, 0.87; P = 0.0001), with an increase in the overall median survival time of 4.67 months. The two groups showed no statistically significant difference in terms of complications for patients with PC (RR, 1.03; P = 0.93) or without PC (RR, 1.15; P = 0.51). CONCLUSION For local AGC without PC, standard surgery combined with prophylactic HIPEC could prolong survival and reduce the recurrence rate without more complications. The prognosis of this treatment strategy for patients with PC is closely related to patient selection. Complete cytoreduction combined with therapeutic HIPEC could prolong survival.
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Affiliation(s)
- Jian-Feng Zhang
- Department of Surgical Oncology and General Surgery, Key Laboratory of Precision Diagnosis and Treatment of Gastrointestinal Tumors, Ministry of Education, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Ling Lv
- Department of Thoracic Surgery, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Shuai Zhao
- Department of Surgical Oncology and General Surgery, Key Laboratory of Precision Diagnosis and Treatment of Gastrointestinal Tumors, Ministry of Education, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Qian Zhou
- Department of Surgical Oncology and General Surgery, Key Laboratory of Precision Diagnosis and Treatment of Gastrointestinal Tumors, Ministry of Education, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Cheng-Gang Jiang
- Department of Surgical Oncology and General Surgery, Key Laboratory of Precision Diagnosis and Treatment of Gastrointestinal Tumors, Ministry of Education, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China.
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Sun BJ, Lee B. Review of Regional Therapies for Gastric Cancer with Peritoneal Metastases. Cancers (Basel) 2022; 14:cancers14030570. [PMID: 35158837 PMCID: PMC8833629 DOI: 10.3390/cancers14030570] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/15/2022] [Accepted: 01/19/2022] [Indexed: 12/20/2022] Open
Abstract
Simple Summary Gastric cancer is usually diagnosed at late stages and is associated with poor five-year survival rates. Metastasis to the peritoneal cavity is common and leads to even worse outcomes. Currently, the mainstay of treatment for metastatic gastric cancer is systemic chemotherapy or supportive care. These recommendations remain despite evidence that suggests systemic therapy has poor penetration into the abdominal cavity, limiting efficacy against peritoneal disease. Newer treatments have been developed to address this problem, specifically regional therapies aimed at delivering chemotherapy directly into the peritoneal cavity to eradicate tumor cells. These novel therapies include hyperthermic intraperitoneal chemotherapy, normothermic intraperitoneal chemotherapy, and pressurized intraperitoneal aerosolized chemotherapy. Regional therapies may also be combined with surgery to remove both macroscopic and microscopic disease. Although more clinical trials are needed to evaluate its efficacy, early studies have shown promising outcomes with intraperitoneal chemotherapy. Abstract Gastric cancer carries a poor prognosis and is a leading cause of cancer-related mortality worldwide. Patients with gastric cancer who develop peritoneal metastases have an even more dismal prognosis, with median survival time measured in months. Since studies have demonstrated that systemic chemotherapy has poor penetration into the peritoneum, multimodal treatment with intraperitoneal chemotherapy has been proposed for the treatment of peritoneal metastases and has become the foundation for newer therapeutic techniques and clinical trials. These include heated intraperitoneal chemotherapy (HIPEC) with cytoreductive surgery (CRS), which involves the application of heated chemotherapy into the abdomen with or without tumor debulking surgery; normothermic intraperitoneal chemotherapy (NIPEC), in which non-heated chemotherapy can be delivered into the abdomen via a peritoneal port allowing for repeat dosing; and pressurized intraperitoneal aerosolized chemotherapy (PIPAC), a newer technique of pressurized and aerosolized chemotherapy delivered into the abdomen during laparoscopy. Early results with intraperitoneal chemotherapy have shown promise in increasing disease-free and overall survival in select patients. Additionally, there may be a palliative effect of these regional therapies. In this review, we explore and summarize these different intraperitoneal chemotherapy treatment regimens for gastric cancer with peritoneal metastases.
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Abstract
Peritoneal surface malignancies comprise a heterogeneous group of primary tumours, including peritoneal mesothelioma, and peritoneal metastases of other tumours, including ovarian, gastric, colorectal, appendicular or pancreatic cancers. The pathophysiology of peritoneal malignancy is complex and not fully understood. The two main hypotheses are the transformation of mesothelial cells (peritoneal primary tumour) and shedding of cells from a primary tumour with implantation of cells in the peritoneal cavity (peritoneal metastasis). Diagnosis is challenging and often requires modern imaging and interventional techniques, including surgical exploration. In the past decade, new treatments and multimodal strategies helped to improve patient survival and quality of life and the premise that peritoneal malignancies are fatal diseases has been dismissed as management strategies, including complete cytoreductive surgery embedded in perioperative systemic chemotherapy, can provide cure in selected patients. Furthermore, intraperitoneal chemotherapy has become an important part of combination treatments. Improving locoregional treatment delivery to enhance penetration to tumour nodules and reduce systemic uptake is one of the most active research areas. The current main challenges involve not only offering the best treatment option and developing intraperitoneal therapies that are equivalent to current systemic therapies but also defining the optimal treatment sequence according to primary tumour, disease extent and patient preferences. New imaging modalities, less invasive surgery, nanomedicines and targeted therapies are the basis for a new era of intraperitoneal therapy and are beginning to show encouraging outcomes.
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38
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Badgwell B. Regional therapy trials in peritoneal metastases: The path to standardization of care for gastric cancer. J Surg Oncol 2021; 125:64-68. [PMID: 34897716 DOI: 10.1002/jso.26718] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/07/2021] [Indexed: 11/08/2022]
Abstract
As the peritoneum is the most common site of metastatic disease at diagnosis, disease identified at staging laparoscopy, and site of recurrence for patients with gastric cancer, intraperitoneal therapy has been an area of interest for many investigators. There are several ways to categorize the existing trials and studies. One is by indication, which includes palliative, neoadjuvant, adjuvant, and prophylactic. Another is by treatment modality which includes approaches such as hyperthermic intraperitoneal chemotherapy, pressurized intraperitoneal aerosol chemotherapy, intraperitoneal normothermic chemotherapy, and bidirectional combinations of systemic and intraperitoneal therapy. Recently completed and ongoing trials of peritoneal therapy in gastric cancer may be improving on the historically dismal survival rates for patients with carcinomatosis or disease at high risk of peritoneal recurrence. All completed randomized trials are from outside the United States, and additional studies of peritoneal therapy in Western populations are needed to clarify survival outcomes. Cooperative group trials and multi-institutional registry study efforts are ongoing to help address this clear area of unmet need.
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Affiliation(s)
- Brian Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Aigner K, Vashist YK, Selak E, Gailhofer S, Aigner KR. Efficacy of Regional Chemotherapy Approach in Peritoneal Metastatic Gastric Cancer. J Clin Med 2021; 10:jcm10225322. [PMID: 34830604 PMCID: PMC8624731 DOI: 10.3390/jcm10225322] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/04/2021] [Accepted: 11/13/2021] [Indexed: 12/22/2022] Open
Abstract
Peritoneal spread is frequent in gastric cancer (GC) and a palliative condition. After failure to systemic chemotherapy (sCTx) remaining therapeutic options are very limited. We evaluated the feasibility and efficacy of locoregional chemotherapy (RegCTx) in peritoneal metastatic GC. In total, 38 (23 male and 15 female) patients with peritoneal metastatic GC after failure of previous sCTx and unresectable disease were enrolled in this study. Using the hypoxic abdominal stop-flow perfusion, upper abdominal perfusion and intraarterial infusion technique in total 114 cycles with Cisplatin, Adriamycin and Mitomycin C were applied. No significant procedure related toxicity was noticed- especially no Grade 3 or 4 toxicity occurred. With the RegCTx approach a median overall survival of 17.4 months was achieved. Patients who had undergone previously resection of the GC the median overall survival was even better with 23.5 months. RegCTx is a promising, safe and efficient approach in diffuse metastatic GC. The evaluation of RegCTx in the setting of multimodal treatment approach at less advanced stages is also warranted.
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40
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Gertsen EC, Brenkman HJF, van Hillegersberg R, van Sandick JW, van Berge Henegouwen MI, Gisbertz SS, Luyer MDP, Nieuwenhuijzen GAP, van Lanschot JJB, Lagarde SM, Wijnhoven BPL, de Steur WO, Hartgrink HH, Stoot JHMB, Hulsewe KWE, Spillenaar Bilgen EJ, van Det MJ, Kouwenhoven EA, van der Peet DL, Daams F, van Grieken NCT, Heisterkamp J, van Etten B, van den Berg JW, Pierie JP, Eker HH, Thijssen AY, Belt EJT, van Duijvendijk P, Wassenaar E, van Laarhoven HWM, Wevers KP, Hol L, Wessels FJ, Haj Mohammad N, van der Meulen MP, Frederix GWJ, Vegt E, Siersema PD, Ruurda JP. 18F-Fludeoxyglucose-Positron Emission Tomography/Computed Tomography and Laparoscopy for Staging of Locally Advanced Gastric Cancer: A Multicenter Prospective Dutch Cohort Study (PLASTIC). JAMA Surg 2021; 156:e215340. [PMID: 34705049 DOI: 10.1001/jamasurg.2021.5340] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Importance The optimal staging for gastric cancer remains a matter of debate. Objective To evaluate the value of 18F-fludeoxyglucose-positron emission tomography with computed tomography (FDG-PET/CT) and staging laparoscopy (SL) in addition to initial staging by means of gastroscopy and CT in patients with locally advanced gastric cancer. Design, Setting, and Participants This multicenter prospective, observational cohort study included 394 patients with locally advanced, clinically curable gastric adenocarcinoma (≥cT3 and/or N+, M0 category based on CT) between August 1, 2017, and February 1, 2020. Exposures All patients underwent an FDG-PET/CT and/or SL in addition to initial staging. Main Outcomes and Measures The primary outcome was the number of patients in whom the intent of treatment changed based on the results of these 2 investigations. Secondary outcomes included diagnostic performance, number of incidental findings on FDG-PET/CT, morbidity and mortality after SL, and diagnostic delay. Results Of the 394 patients included, 256 (65%) were men and mean (SD) age was 67.6 (10.7) years. A total of 382 patients underwent FDG-PET/CT and 357 underwent SL. Treatment intent changed from curative to palliative in 65 patients (16%) based on the additional FDG-PET/CT and SL findings. FDG-PET/CT detected distant metastases in 12 patients (3%), and SL detected peritoneal or locally nonresectable disease in 73 patients (19%), with an overlap of 7 patients (2%). FDG-PET/CT had a sensitivity of 33% (95% CI, 17%-53%) and specificity of 97% (95% CI, 94%-99%) in detecting distant metastases. Secondary findings on FDG/PET were found in 83 of 382 patients (22%), which led to additional examinations in 65 of 394 patients (16%). Staging laparoscopy resulted in a complication requiring reintervention in 3 patients (0.8%) without postoperative mortality. The mean (SD) diagnostic delay was 19 (14) days. Conclusions and Relevance This study's findings suggest an apparently limited additional value of FDG-PET/CT; however, SL added considerably to the staging process of locally advanced gastric cancer by detection of peritoneal and nonresectable disease. Therefore, it may be useful to include SL in guidelines for staging advanced gastric cancer, but not FDG-PET/CT.
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Affiliation(s)
- Emma C Gertsen
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Hylke J F Brenkman
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Johanna W van Sandick
- Department of Surgery, the Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam University Medical Center, location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam University Medical Center, location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Jan J B van Lanschot
- Department of Surgery, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Sjoerd M Lagarde
- Department of Surgery, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Wobbe O de Steur
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Henk H Hartgrink
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Jan H M B Stoot
- Department of Surgery, Zuyderland MC, Sittard-Geleen, the Netherlands
| | - Karel W E Hulsewe
- Department of Surgery, Zuyderland MC, Sittard-Geleen, the Netherlands
| | | | - Marc J van Det
- Department of Surgery, ZGT hospital, Almelo, the Netherlands
| | | | - Donald L van der Peet
- Department of Surgery, Amsterdam University Medical Center, location VUmc, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam University Medical Center, location VUmc, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Nicole C T van Grieken
- Department of Pathology, Amsterdam University Medical Center, location VUmc, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Joos Heisterkamp
- Department of Surgery, Elisabeth Twee-Steden Hospital, Tilburg, the Netherlands
| | - Boudewijn van Etten
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Jan Willem van den Berg
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Jean Pierre Pierie
- Department of Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Hasan H Eker
- Department of Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Annemieke Y Thijssen
- Department of Gastroenterology, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Eric J T Belt
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | | | - Eelco Wassenaar
- Department of Surgery, Gelre Ziekenhuizen, Apeldoorn, the Netherlands
| | - Hanneke W M van Laarhoven
- Prospective Observational Cohort Study of Oesophageal-Gastric Cancer Patients (POCOP) of the Dutch Upper GI Cancer Group, Amsterdam, the Netherlands.,Department of Medical Oncology, Amsterdam University Medical Center, location AMC, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Kevin P Wevers
- Department of Surgery, Isala Ziekenhuis, Zwolle, the Netherlands
| | - Lieke Hol
- Department of Gastroenterology, Maasstad Ziekenhuis, Rotterdam, the Netherlands
| | - Frank J Wessels
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Nadia Haj Mohammad
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Miriam P van der Meulen
- Julius Center for Health Sciences and Primary Care, Utrecht University, Utrecht, the Netherlands
| | - Geert W J Frederix
- Julius Center for Health Sciences and Primary Care, Utrecht University, Utrecht, the Netherlands
| | - Erik Vegt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Peter D Siersema
- Department of Gastroenterology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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The Burden of Peritoneal Metastases from Gastric Cancer: A Systematic Review on the Incidence, Risk Factors and Survival. J Clin Med 2021; 10:jcm10214882. [PMID: 34768402 PMCID: PMC8584453 DOI: 10.3390/jcm10214882] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/18/2021] [Accepted: 10/21/2021] [Indexed: 12/22/2022] Open
Abstract
The peritoneum is a common metastatic site in gastric cancer. This systematic review provides an overview of the incidence, risk factors and survival of synchronous peritoneal metastases from gastric cancer. A systematic search was performed to identify studies wherein the incidence, risk factors and survival of gastric cancer with peritoneal metastases were investigated. Of all 38 potentially eligible studies, 17 studies were included based on the eligibility criteria. The incidence of synchronous gastric peritoneal metastases was reviewed for population-based studies (10–21%), for observational cohort studies (2–15%) and for surgical cohort studies (13–40%). Potential risk factors for synchronous gastric peritoneal metastases were younger age, non-cardia gastric cancer, female sex, signet ring cell carcinoma, diffuse type histology or linitis plastica, T4 stage, Hispanic ethnicity and more than one metastatic location. Synchronous peritoneal metastases are commonly diagnosed in patients with gastric cancer with an incidence up to 21% in recent population-based studies. Furthermore, prognosis of patients with gastric peritoneal metastases is poor with median overall survival ranging from 2 to 9 months. The high incidence and poor prognosis require intensive research on diagnostic features and effective treatment options to improve survival.
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42
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Laparoscopic Heated Intraperitoneal Chemotherapy in the Treatment of Carcinomatosis of Gastric Adenocarcinoma Origin. J Clin Med 2021; 10:jcm10204757. [PMID: 34682880 PMCID: PMC8539356 DOI: 10.3390/jcm10204757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/09/2021] [Accepted: 10/15/2021] [Indexed: 11/30/2022] Open
Abstract
The use of heated intraperitoneal chemotherapy (HIPEC) in conjunction with cytoreductive surgery has been gaining increasing traction in treating gastric adenocarcinoma with metastasis to the peritoneum in recent years. The addition of laparoscopic HIPEC (LS-HIPEC) to these treatment algorithms has increased the flexibility and adaptability of HIPEC integrating into treatment sequencing, allowing for iterative protocols of LS-HIPEC prior to cytoreduction as neoadjuvant treatment, as well as in the palliation of patients with unresectable disease and uncontrolled ascites. As the use of HIPEC in gastric adenocarcinoma continues to be refined, LS-HIPEC algorithms should continue to be considered and utilized both in curative treatment algorithms as well as in patients in the palliative setting. Given that LS-HIPEC remains a relatively nascent treatment modality, we advocate for its use in the setting of a clinical trial when feasible.
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Ruiz Hispán E, Pedregal M, Cristobal I, García-Foncillas J, Caramés C. Immunotherapy for Peritoneal Metastases from Gastric Cancer: Rationale, Current Practice and Ongoing Trials. J Clin Med 2021; 10:4649. [PMID: 34682772 PMCID: PMC8539177 DOI: 10.3390/jcm10204649] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/07/2021] [Accepted: 10/08/2021] [Indexed: 02/07/2023] Open
Abstract
Peritoneal metastases from gastric cancer play a key role in the fatal prognosis of the disease. The lack of efficacy of actual therapeutic approaches together with the outcomes achieved with checkpoint inhibitors in gastric cancer compel us to address the current state-of-the-art immunotherapy treatment of peritoneal dissemination. The immunogenicity of the peritoneum has been described to be particularly active at omentum and peritoneal lymph nodes. Also, both innate and acquired immunity seems to be involved at different molecular levels. Recent works show PDL1 expression being less present at the peritoneal level; however, some clinical trials have begun to yield results. For example, the ATTRACTION-2 trial has demonstrated the activity of Nivolumab in heavily pretreated patients even though peritoneal metastases were diagnosed in a 30% of them. Despite positive results in the metastatic setting, peritoneal responses to systemic checkpoint inhibitors remains unclear, therefore, new strategies for intraperitoneal immunotherapy are being proposed for different ongoing clinical trials.
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Affiliation(s)
- Eva Ruiz Hispán
- Department of Oncology, Fundación Jiménez Díaz University Hospital, IIS-Fundación Jiménez Díaz, 28040 Madrid, Spain; (E.R.H.); (M.P.)
| | - Manuel Pedregal
- Department of Oncology, Fundación Jiménez Díaz University Hospital, IIS-Fundación Jiménez Díaz, 28040 Madrid, Spain; (E.R.H.); (M.P.)
| | - Ion Cristobal
- Cancer Unit for Research on Novel Therapeutic Targets, Oncohealth Institute, IIS-Fundación Jiménez Díaz-UAM Madrid, 28040 Madrid, Spain;
| | - Jesús García-Foncillas
- Department of Oncology, Fundación Jiménez Díaz University Hospital, IIS-Fundación Jiménez Díaz, 28040 Madrid, Spain; (E.R.H.); (M.P.)
| | - Cristina Caramés
- Department of Oncology, Fundación Jiménez Díaz University Hospital, IIS-Fundación Jiménez Díaz, 28040 Madrid, Spain; (E.R.H.); (M.P.)
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Caspers IA, Sikorska K, Slagter AE, van Amelsfoort RM, Meershoek-Klein Kranenbarg E, van de Velde CJH, Lind P, Nordsmark M, Jansen EPM, Verheij M, van Sandick JW, Cats A, van Grieken NCT. Risk Factors for Metachronous Isolated Peritoneal Metastasis after Preoperative Chemotherapy and Potentially Curative Gastric Cancer Resection: Results from the CRITICS Trial. Cancers (Basel) 2021; 13:cancers13184626. [PMID: 34572852 PMCID: PMC8469213 DOI: 10.3390/cancers13184626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/10/2021] [Accepted: 09/12/2021] [Indexed: 12/09/2022] Open
Abstract
Simple Summary Around 20% of gastric cancer patients develop peritoneal metastasis after preoperative chemotherapy and curative surgery. Patients with peritoneal metastasis as a single site of metastasis may potentially benefit from prophylactic strategies. In this post-hoc analysis of the international phase III CRITICS trial, we aim to identify factors that can distinguish patients at high risk for developing peritoneal metastasis as a single site. Diffuse or mixed histological subtype, tumors with serosal involvement (ypT4) and advanced lymph node stage (ypN3 or a tumor positive lymph node ratio >20%) were independent risk factors for isolated peritoneal metastasis after preoperative chemotherapy and curative surgery. The combination of these risk factors identifies a subgroup that may benefit from treatment strategies that aim to prevent peritoneal metastasis. Abstract Gastric cancer (GC) patients at high risk of developing peritoneal metastasis (PM) as a single site of metastasis after curative treatment may be candidates for adjuvant prophylactic strategies. Here we investigated risk factors for metachronous isolated PM in patients who were treated in the CRITICS trial (NCT00407186). Univariable and multivariable analyses on both metachronous isolated PM and ‘other events’, i.e., (concurrent) distant metastasis, locoregional recurrence or death, were performed using a competing risk model and summarized by cumulative incidences. Isolated PM occurred in 64 of the 606 (11%) included patients. Diffuse or mixed histological subtype, ypT4 tumor stage and LNhigh (ypN3 lymph node stage or a lymph node ratio >20%) were independent risk factors for isolated PM in both univariable and multivariable analyses. Likewise, LNhigh was an independent risk factor for ‘other events’. Patients with tumors who were positive for all three independent risk factors had the highest two-year cumulative incidence of 43% for isolated PM development. In conclusion, diffuse or mixed histological subtype, ypT4 and LNhigh were identified as independent risk factors for isolated PM in patients treated with preoperative chemotherapy followed by surgical resection. The combination of these factors may identify a subgroup that may benefit from PM-preventing treatment strategies.
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Affiliation(s)
- Irene A. Caspers
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands; (I.A.C.); (A.C.)
- Department of Pathology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Karolina Sikorska
- Department of Biometrics, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands;
| | - Astrid E. Slagter
- Department of Radiation Oncology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands; (A.E.S.); (R.M.v.A.); (E.P.M.J.); (M.V.)
| | - Romy M. van Amelsfoort
- Department of Radiation Oncology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands; (A.E.S.); (R.M.v.A.); (E.P.M.J.); (M.V.)
| | | | | | - Pehr Lind
- Department of Oncology, Stockholm Söder Hospital, 118 83 Stockholm, Sweden;
- Department of Oncology and Pathology, Karolinska Institute, 171 77 Stockholm, Sweden
| | - Marianne Nordsmark
- Department of Medical Oncology, Aarhus University, 8200 Aarhus, Denmark;
| | - Edwin P. M. Jansen
- Department of Radiation Oncology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands; (A.E.S.); (R.M.v.A.); (E.P.M.J.); (M.V.)
| | - Marcel Verheij
- Department of Radiation Oncology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands; (A.E.S.); (R.M.v.A.); (E.P.M.J.); (M.V.)
- Department of Radiation Oncology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Johanna W. van Sandick
- Department of Surgery, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands;
| | - Annemieke Cats
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands; (I.A.C.); (A.C.)
| | - Nicole C. T. van Grieken
- Department of Pathology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, 1081 HV Amsterdam, The Netherlands
- Correspondence:
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Kamarajah SK, Markar SR, Phillips AW, Salti GI, Dahdaleh F, Griffiths EA. Palliative gastrectomy for metastatic gastric adenocarcinoma: A national population-based cohort study. Surgery 2021; 170:1702-1710. [PMID: 34389165 DOI: 10.1016/j.surg.2021.07.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/21/2021] [Accepted: 07/14/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The impact of palliative gastrectomy for metastatic gastric adenocarcinoma, especially by site of metastasis remains unclear. METHODS The National Cancer Database, 2010-2015, was used to identify patients with clinical metastatic (cM1) gastric adenocarcinoma (n = 19,411) at diagnosis. The main variable was index management for cM1 gastric adenocarcinoma (ie, no treatment, palliative chemotherapy, or palliative gastrectomy). Cox multivariable analyses were used to account for treatment selection bias and reported as hazard ratio (HR) and 95% confidence interval. RESULTS Of 19,411 patients, 10,893 (56%) received palliative chemotherapy, and only 1,101 (6%) received palliative gastrectomy only. The median survival was 6.1 months, and 5-year survival was 4% in the entire cohort. Patients receiving palliative gastrectomy had a significantly longer survival than patients without any treatment or palliative chemotherapy (median: 12.8 vs 1.8 vs 9.5 months, P < .001), which remained after multivariable adjustment (HR: 0.76, 95% confidence interval: 0.71-0.81, P < .001) compared with palliative chemotherapy. Stratified analyses by clinical nodal stage (cN) demonstrated survival benefit with palliative gastrectomy: cN0 (HR: 0.71, 95% confidence interval: 0.62-0.82), cN1 (HR: 0.68, 95% confidence interval: 0.59-0.79), cN2 (HR: 0.86, 95% confidence interval: 0.70-0.94), and cN3 (HR: 0.82, 95% confidence interval: 0.70-0.92) over palliative chemotherapy. Stratified analyses by metastasis site demonstrated that palliative gastrectomy remained superior compared with palliative chemotherapy for metastatic disease limited to liver, bone, and peritoneum, but equivalent to lung metastasis and inferior to brain metastasis. CONCLUSION Palliative gastrectomy appears to have a modest survival benefit over palliative chemotherapy alone. Differences in outcomes by site of metastasis warrant further research to understand tumor biology and identify specific subgroups which may benefit from palliative gastrectomy.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, UK. https://twitter.com/Sivesh93
| | - Sheraz R Markar
- Department of Surgery & Cancer, Imperial College London, London United Kingdom; Department of Molecular Medicine, Karolinska Institutet, Stockholm, Sweden. https://twitter.com/MarkarSheraz
| | - Alexander W Phillips
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle-Upon-Tyne, UK; School of Medical Education, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK. https://twitter.com/AlexWPhillips7
| | - George I Salti
- Department of General Surgery, University of Illinois Hospital and Health Sciences System, Chicago, IL; Edward-Elmhurst Health, Department of Surgical Oncology, Naperville, IL. https://twitter.com/DrGeorgeSalti
| | - Fadi Dahdaleh
- Edward-Elmhurst Health, Department of Surgical Oncology, Naperville, IL. https://twitter.com/fdahdaleh
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, UK.
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Staging laparoscopy in patients with advanced gastric cancer: A single center cohort study. Eur J Surg Oncol 2021; 48:362-369. [PMID: 34384656 DOI: 10.1016/j.ejso.2021.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/29/2021] [Accepted: 08/05/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Most studies exploring the role of staging laparoscopy in gastric cancer are limited by low sample size and are predominantly conducted in Asian countries. This study sets out to determine the value of staging laparoscopy in patients with advanced gastric cancer in a Western population. METHODS All patients with gastric cancer from a tertiary referral center without definite evidence of non-curable disease after initial staging, and who underwent staging laparoscopy between 2013 and 2020, were identified from a prospectively maintained database. The proportion of patients in whom metastases or locoregional non-resectability was detected during staging laparoscopy was established. Secondary outcomes included the avoidable surgery rate (detection of non-curable disease during gastrectomy with curative intent) and diagnostic accuracy (sensitivity, specificity, accuracy, negative and positive predictive value). RESULTS A total of 216 patients were included. Staging laparoscopy revealed metastatic disease in 46 (21.3 %) patients and a non-resectable tumor in three (1.4 %) patients. During intended gastrectomy, non-curable disease was revealed in 13 (8.6 %) patients. Overall sensitivity, specificity and diagnostic accuracy were 76.6 %, 100 % and 92.6 %, respectively. The positive predictive value was 100 % and the negative predictive value was 90.3 %. CONCLUSION Staging laparoscopy is valuable in the staging process of gastric cancer with a high accuracy in detecting non-curable disease, thereby preventing futile treatment and its associated burden.
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Hishida T, Masai K, Kaseda K, Asakura K, Asamura H. Debulking surgery for malignant tumors: the current status, evidence and future perspectives. Jpn J Clin Oncol 2021; 51:1349-1362. [PMID: 34254145 DOI: 10.1093/jjco/hyab107] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 06/22/2021] [Indexed: 11/14/2022] Open
Abstract
Debulking surgery, also called cytoreductive surgery, is a resection of the tumor as much as possible and an intended incomplete resection for unresectable malignant tumors. Since the most important principle in surgical oncology is complete R0 resection, debulking surgery goes against the basic principle and obscures the concept of operability. However, debulking surgery has been advocated for various types of advanced malignant tumors, including gynecological cancers, urological cancers, gastrointestinal cancers, breast cancers and other malignancies, with or without adjuvant therapy. Positive data from randomized trials have been shown in subsets of ovarian cancer, renal cell carcinoma, colorectal cancer and breast cancer. However, recent trials for renal cell carcinoma, colorectal cancer and breast cancer have tended to show controversial results, mainly according to the survival improvement of nonsurgical systemic therapy alone. On the other hand, debulking surgery still has a therapeutic role for slow-growing and borderline malignant tumors, such as pseudomyxoma peritonei and thymomas. The recent understanding of tumor heterogeneity and clonal evolution responsible for malignancy and drug resistance indicates that select patients may obtain prolonged survival by the synergistic effect of debulking surgery and novel systemic therapy. This review aimed to describe the current status and evidence of debulking surgery in a cross-organ manner and to discuss future perspectives in the current era with advances in systemic therapy.
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Affiliation(s)
| | | | | | | | - Hisao Asamura
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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Koemans WJ, Lurvink RJ, Grootscholten C, Verhoeven RHA, de Hingh IH, van Sandick JW. Synchronous peritoneal metastases of gastric cancer origin: incidence, treatment and survival of a nationwide Dutch cohort. Gastric Cancer 2021; 24:800-809. [PMID: 33495964 DOI: 10.1007/s10120-021-01160-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 01/11/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The peritoneum is a predilection site for gastric cancer metastases. Current standard treatment for gastric cancer patients with synchronous peritoneal metastases is palliative systemic therapy. However, its efficacy is largely unknown. The aim of this study was to investigate the incidence, treatment and survival patterns of gastric cancer patients with synchronous peritoneal metastases in the Netherlands. METHODS All newly diagnosed gastric adenocarcinoma patients with synchronous peritoneal metastases between 1999 and 2017 were selected from the Netherlands Cancer Registry (NCR). Incidence, treatment and survival patterns were analyzed. RESULTS In total, 3,773 patients were identified from the NCR. The incidence of synchronous peritoneal metastases in gastric cancer patients increased from 18% in 2008 to 27% in 2017. The use of systemic therapy increased from 15% in 1999-2002 to 43% in 2013-2017 (p < 0.001). The median survival of the entire cohort did not significantly increase over time. Median survival of patients treated with systemic therapy increased from 7.4 months in 1999-2002 to 9.4 months in 2013-2017 (p = 0.005). In contrast, median survival of patients not treated with systemic therapy decreased from 3.3 months in 1999-2002 to 2.1 months in 2013-2017 (p < 0.001). Some clinical and pathological data such as the extent of the peritoneal metastases were not available. CONCLUSION Synchronous peritoneal metastases are increasingly diagnosed in gastric cancer patients. In recent years, more patients were treated with systemic treatment and survival of these patients increased. However, as survival of the entire group did not improve over time, the effect of systemic therapy remains unknown.
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Affiliation(s)
- Willem J Koemans
- Department of Surgical Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Robin J Lurvink
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands
| | - Cecile Grootscholten
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Rob H A Verhoeven
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Johanna W van Sandick
- Department of Surgical Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
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Gertsen EC, Brenkman HJF, Haverkamp L, Read M, Ruurda JP, van Hillegersberg R. Worldwide Practice in Gastric Cancer Surgery: A 6-Year Update. Dig Surg 2021; 38:266-274. [PMID: 34062540 DOI: 10.1159/000515768] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 03/08/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aim of the study was to evaluate the current status of gastric cancer surgery worldwide and update the changes compared to a previous survey in 2014. METHODS A cross-sectional survey was sent to surgical members of the International Gastric Cancer Association, pilot centers of the World Organization for Specialized Studies on Diseases of the Esophagus, and the Australian and New Zealand Gastric and Oesophageal Surgeons Association in addition to participants of the 2019 International Gastric Cancer and European Society for Diseases of the Esophagus congresses. Topics addressed included hospital volume, staging, perioperative treatment, surgical approach, anastomotic techniques, lymphadenectomy, and palliative management. RESULTS Between June 2019 and January 2020, 165 respondents from 44 countries completed the survey. In total, 80% worked in a hospital performing >20 gastrectomies annually. Staging laparoscopy and 18F-fluorodeoxyglucose positron emission tomography with computed tomography were preferred by 68 and 26% for advanced cancer, and 90% offered perioperative chemo(radio)therapy to patients. For early cancer, a minimally invasive surgical approach was preferred by 65% for distal and by 50% for total gastrectomy. For advanced cancer, this was preferred by 39% for distal and by 33% for total gastrectomy. And 84% favored a stapled anastomosis, and 14% created a jejunal pouch as reconstruction during total gastrectomy. A D2 lymphadenectomy was preferred for distal as well as for total gastrectomy, in both early (62 and 71%) and advanced (84 and 89%) cancer. CONCLUSION This international survey demonstrates that perioperative chemotherapy and a D2 lymphadenectomy have now become the preferred treatment for gastric cancer. A minimally invasive surgical approach has gained popularity.
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Affiliation(s)
- Emma C Gertsen
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Hylke J F Brenkman
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands
| | - Leonie Haverkamp
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Matthew Read
- Department of Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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50
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Harris MC, Cockbain AJ, McQuillan PW, Kanhere HA. Survey and literature review on the importance of peritoneal cytology in staging and treatment of gastric cancer: always wash it before you treat it. ANZ J Surg 2021; 91:13-18. [PMID: 33590628 DOI: 10.1111/ans.16295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 08/12/2020] [Accepted: 08/13/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Mark C Harris
- Division of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.,School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Andrew J Cockbain
- Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Patrick W McQuillan
- Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Harsh A Kanhere
- Division of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.,School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia.,Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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