Optimal locoregional treatment in gastric cancer

Significance of nodal dissection and nodal positivity in gastric cancer

Lymphadenectomy is a central component of surgery for gastric cancer. However, controversies over the optimal extent of lymphadenectomy in gastric cancer surgery have persisted for several decades. In Eastern countries where the incidence of gastric cancer is high, surgeons have performed extensive lymphadenectomy (D2 lymphadenectomy) with low morbidity and mortality, while most Western surgeons have advocated for more limited lymphadenectomies according to the results of Dutch trial and MRC trial. Initially, these trials had failed to show survival benefit of D2 procedure and instead, found pancreaticosplenectomy performed as part of the D2 procedure associated with high incidence of morbidity and mortality. Subsequently, superiority of D2 lymphadenectomy on survival was demonstrated based on updated results. Moreover, spleen and pancreas preserving D2 lymphadenectomy are being performed safely in Western countries. Today, there is an international consensus on performing D2 lymphadenectomy as the standard procedure for advanced gastric cancer and is widely accepted as the standard procedure for gastric cancer surgery. The significance of the extent of lymphadenectomy is intimately associated with the prognostic importance of nodal metastases as the most powerful indicator of recurrence and survival for patients after curative gastrectomy. Maruyama computer program could be used to estimate the risk of lymph node metastasis in each nodal station. The Maruyama Index could be used to assess the adequacy of lymphadenectomy in gastric cancer. Positive lymph node ratio is calculated as the ratio of positive lymph nodes to all harvested lymph nodes, which might be a more precise predictor of prognosis than the absolute number of positive lymph nodes. While D2 lymphadenectomy enables the accurate staging of the disease, reduces the incidence of locoregional recurrences and thus contribute to an improved overall survival; performing lymphadenectomy beyond D2 is unlikely to improve survival. Therapeutic D2+ lymphadenectomy for advanced gastric cancer requires further evaluations, especially for patients receiving neo-adjuvant or conversion treatments.

Prognostic impact of the number of retrieved lymph nodes in patients with gastric cancer

BACKGROUND

In gastric cancer, although at least 16 lymph nodes of retrieved lymph nodes (RLNs) are recommended for nodal staging in Japanese Classification of Gastric Carcinoma and TNM classifications, we wished to clarify their appropriateness.

STUDY DESIGN

A total of 1289 consecutive gastric cancer patients, who underwent gastrectomy between 1997 and 2011, were analyzed retrospectively.

RESULTS

(i) The patients were divided into two groups using a cut-off RLN number of 16 (RLN < 16 or RLN ≥ 16). There were significant differences in the survival rates of patients in pStage II (P < 0.0001) and III (P = 0.0009), but not those of patients in pStage I (P = 0.0627) and IV (P = 0.1553). (ii) In 498 consecutive patients in pStage II and III, compared with patients in the RLN ≥ 16 group, those in the RLN < 16 group had a significantly higher incidence of older age (P = 0.0004) and positive lymph node ratio (PLNR) (P < 0.0001). Univariate and multivariate analyses showed that an RLN number of less than 16 was an independent poor prognostic factor (P < 0.0001, HR 2.48 [95% CI: 1.60-3.70]). (iii) A cut-off RLN number of 16 could cause the stage migration effect in pStage II or III patients. A cut-off RLN number of 25 or more could eliminate the prognostic effect.

CONCLUSION

The RLN number may potentially affect the prognosis and the stage migration in pStage II or III gastric cancer patients. An RLN number of 25 or more could be sufficient for nodal staging.

The Essentials of Locoregional Control in the Treatment of Gastric Cancer

Gastric cancer is the fourth most frequent cancer in the world. For curative treatment and local control of gastric cancer, surgery is essential. The extent of the lymph node dissection is still under debate. Only one available trial showed significantly increased overall survival, whereas in all other randomised trials no significant difference could be found.

As surgery alone often is not sufficient in the curative treatment in gastric cancer, different (neo)adjuvant treatment strategies have extensively been studied. The recently published MAGIC trial showed downstaging, downsizing and an improved overall survival for patients treated with perioperative chemotherapy, compared to surgery alone (difference 13%, p = 0.009). The INT 0116 trial on the other hand, demonstrated the benefit of postoperative chemoradiotherapy compared to surgery alone for patients with a curative resection of gastric cancer. However, the quality of resections in this trial was poor, illustrating the importance of standardisation by quality control. This could be done by the Maruyama index, which quantifies the likelihood of unresected disease.

In the Netherlands, the CRITICS trial has recently been launched, which will be a quality controlled trial comparing postoperative chemoradiotherapy and chemotherapy on survival and/or locoregional control in patients who receive neoadjuvant chemotherapy followed by a D1+ gastric resection.

Clinical significance and prognostic impact of the total diameter of enlarged lymph nodes on preoperative multidetector computed tomography in patients with gastric cancer

BACKGROUND AND AIM

This study was designed to evaluate the clinical significance and prognostic impact of the total diameter of enlarged lymph nodes (TDL) on preoperative multidetector computed tomography (MDCT) in gastric cancer (GC).

METHODS

Of a total of 480 GC patients between 2005 and 2009, 70 patients with a preoperative diagnosis of nodal metastasis on MDCT were included in this study. All regional lymph nodes showing metastatic involvement were preoperatively counted and measured.

RESULTS

The TDL was calculated, and using a receiver operating characteristic curve, a cutoff value of 45 mm in the two groups of large TDL (LTDL) and small TDL was found to be appropriate for TDL. No significant differences were observed in clinicopathological features, except for tumor recurrence, between the two groups. Univariate survival analysis revealed that patients with LTDL had a worse prognosis as well as an upper tumor location, deeper tumor depth, and further advanced pathological stage. Multivariable prognostic analysis identified LTDL as an independent worse prognostic factor (P = 0.0128).

CONCLUSIONS

GC patients with the total nodal diameter measuring 45 mm or more on MDCT have a worse prognosis. GC patients with the novel surrogate indicator of worse prognosis for a preoperative imaging diagnosis may have need of multimodal treatment to improve the survival.

Inhibition of mTOR signalling potentiates the effects of trichostatin A in human gastric cancer cell lines by promoting histone acetylation

Deregulation of the mammalian target of rapamycin pathway (mTOR pathway) is associated with human cancer. The relationship between mTOR pathway and histone acetylation is still unclear in gastric cancer (GC). Immunohistochemistry was used to examine the phosphorylation of mTOR and eukaryotic translation initiation factor 4E-binding protein 1 (4E-BP1) in GC tissues. MKN45 and SGC7901 cells were treated with the mTOR inhibitor rapamycin (RAPA) alone or in combination with the phosphatidylinositol 3-kinase inhibitor LY294002 and the histone deacetylase (HDAC) inhibitor trichostatin A (TSA). Small interfering RNA (siRNA) technology was also used to knockdown mTOR. Phosphorylated mTOR and phosphorylated 4E-BP1 were expressed in 71.1% and 68.4% of the human GC tissues tested, respectively; significantly higher than the levels in para-cancerous tissues (50% and 57.9%) and normal tissues (44.6% and 29%). RAPA markedly inhibited cell proliferation, induced G1 cell cycle arrest, and reduced phosphorylation of p70 S6 protein kinase (p70S6K) and 4E-BP1 in GC cells, particularly when used in combination with LY294002 or TSA. The mRNA expression of the tumour suppressor gene p21(WAF1) increased significantly in GC cells treated with both RAPA and TSA. Histone acetylation also increased after RAPA and TSA treatment or siRNA knockdown of mTOR. Our findings suggest that the mTOR pathway is activated in GC, and also that inhibition of mTOR enhances the ability of TSA to suppress cell proliferation and lead to cell cycle arrest via increasing histone acetylation and p21(WAF1) transcription in human MKN45 and SGC7901 GC cells.

Basal renal function reserve and mean kidney dose predict future radiation-induced kidney injury in stomach cancer patients

BACKGROUND

Adjuvant chemoradiotherapy (CRT) improves the survival in patients with locally advanced stomach cancer. The kidneys are the major dose-limiting organs for radiotherapy (RT) in upper abdominal cancers. We aimed to evaluate the impact of adjuvant CRT on renal function of patients with stomach cancer.

MATERIAL AND METHODS

Fifty-nine stomach cancer patients who underwent postoperative CRT were included. Demographic parameters (age, gender), and basal and 12th-month biochemical parameters were recorded. Mean kidney dose (MKD) administered was determined. Estimated glomerular filtration rate (eGFR) was calculated by modification of diet in renal disease formula.

RESULTS

Fifty-nine patients were recruited (age 60.8 ± 11.9 years; female/male 25/34; follow-up duration 15.6 ± 9.8 months). Twenty-one patients (35.6 %) had basal eGFR <90 ml/min/1.73 m(2). When the basal and 12th-month eGFR was compared, eGFR decreased in 27 patients (45.8 %), whereas eGFR remained stable in 32 (54.2 %) patients. Cox regression analyses revealed that a MKD ≥1,500 cGy and basal eGFR <90 ml/min/1.73 m(2) significantly increased the risk of a decreased eGFR at 12th month (HR = 2.288, 95 % CI 1.009-5.188, p = 0.048 and HR = 2.854, 95 % CI 1.121-7.262, p = 0.028, respectively).

CONCLUSION

MKD ≥1,500 cGy and a basal eGFR <90 ml/min/1.73 m(2) significantly increased the risk of a decreased eGFR at 12th month. We suggest that patients with stomach cancer be evaluated for their basal renal reserve prior to RT, and it may be more convenient to further minimize the dose to the kidneys with more sophisticated RT techniques in patients with stomach cancer, more specifically in patients with decreased renal reserve.

D2 lymphadenectomy with surgical ex vivo dissection into node stations for gastric adenocarcinoma can be performed safely in Western patients and ensures optimal staging

BACKGROUND

The AJCC recommends examination of >16 nodes to stage gastric adenocarcinoma. D2 lymphadenectomy (LAD) followed by surgical ex vivo dissection (SEVD) into nodal stations is standard at many high-volume Asian centers, but potential increases in morbidity and mortality have slowed adoption of D2 LAD in some Western centers.

METHODS

A total of 331 patients with gastric adenocarcinoma who underwent surgical resection at one Western institution from 1995 to 2010 were examined.

RESULTS

Median age of patients was 69 years old, 65% were male, and 84% were white. D1 LAD was performed in 285 patients (86%) and D2 LAD in 46 patients (14%), with SEVD being performed in 17 patients (37%) in the D2 group. D2 LAD with or without SEVD was performed much more commonly between 2006 and 2010. For the D1, D2 without SEVD, and D2 with SEVD groups, the median number of examined nodes and percentage with >16 examined nodes were 16 and 51%, 27 and 93%, and 40 and 100%, respectively. Major complications occurred in 16% of the D1 group and 17% of the D2 group (p>0.05), and 30-day mortality was 3% for the D1 group and 0% for the D2 group. D2 LAD was a positive prognostic factor for overall survival on univariate (p=0.027) and multivariate analyses (p=0.005), but there were several possible confounding variables.

CONCLUSIONS

D2 LAD at our Western institution was performed with low morbidity and no mortality. Optimal staging occurred after D2 LAD combined with SEVD, where a median of 40 nodes were examined and all patients had >16 examined nodes.

Impact of obesity on early surgical and oncologic outcomes after total gastrectomy with "over-D1" lymphadenectomy for gastric cancer

INTRODUCTION

The purpose of the present study was to assess the impact of body mass index (BMI) on perioperative and pathologic outcomes after total gastrectomy with "over-D1" dissection for gastric cancer.

METHODS

Data on 161 patients undergoing total gastrectomy between 2005 and 2011 were reviewed. Patients were grouped into three categories by BMI: BMI < 25 kg/m(2) (63 normal-weight patients; 39.1 %), BMI ≥ 25-<30 kg/m(2) (73 overweight patients; 45.3 %), and BMI ≥ 30 kg/m(2) (25 obese patients; 15.6 %) and matched for the analysis of perioperative and cancer-related outcomes.

RESULTS

Operative time was longer for obese patients. Medical (mainly pulmonary) and surgical (mainly bleeding and wound infection) complications occurred more frequently in overweight/obese subjects. However, they were mostly managed conservatively (grade I-II in the Clavien-Dindo classification). The overall postoperative mortality was 0.9 %. Multivariate analysis identified the American Society of Anesthesiologists score and splenectomy, but not obesity, as independent risk factors for postoperative complications. The median number of lymph nodes retrieved differed significantly from group to group: obese 21 (IQR 18-26), versus overweight 24, versus normal weight 28 (p = 0.031). No difference was found in lymph node ratio and cancer-related parameters.

CONCLUSIONS

Obese patients with operable gastric cancer can be candidates for standard extensive surgical resection, provided that pre-existing co-morbidities and potential intraoperative and postoperative complications are considered.

Total gastrectomy with "over-D1" lymph node dissection: what is the actual impact of age?

BACKGROUND

We aimed to evaluate risk factors for postoperative complications after total gastrectomy with "over-D1" lymphadenectomy.

METHODS

Data on 161 patients (54 cases aged >75 years: elderly group) operated on between 2005 and 2011 were reviewed. Risk factors analyzed for complications (Clavien-Dindo classification) included sex, age, American Society of Anesthesiologists (ASA) grade, body mass index (BMI), pTNM stage, long-term antiplatelets therapy, operative time, and splenectomy.

RESULTS

The median age of the study population was 71 (interquartile range [IQR] 62-77) years (79 [range 76-90] years for elderly patients vs 65 [range 33-75] years for the control group, P < .0001). ASA classification was the only baseline characteristic significantly different in the intergroup analysis; 79.6% of the elderly patients were in ASA class III to IV versus 39.2% of the controls (P < .0001). Univariate analysis showed that patient age, ASA score, BMI, and splenectomy were predictive of postoperative complications. Multivariate analysis confirmed ASA score and splenectomy as independent risk-factors.

CONCLUSIONS

Regardless of age, fit elderly patients with operable gastric cancer should be candidates for the recommended standard extensive surgical resection provided that pre-existing comorbidities are considered.

Bimonthly regimen of high-dose leucovorin, infusional 5-fluorouracil, epirubicin and cisplatin (modified ECF) as adjuvant chemotherapy in resected gastric adenocarcinoma

BACKGROUND

The administration of the de Gramont regimen in combination with cisplatin and epirubicin (modified ECF) has previously been reported as a treatment for advanced gastric cancer, but here we report this regimen combination in an adjuvant setting for the first time.

METHODS

Forty-eight patients with curatively resected gastric cancer were treated. Each 2-week cycle consisted of epirubicin (50 mg/m(2)), cisplatin (50 mg/m(2)), 5-fluorouracil (5-FU) IV bolus (400 mg/m(2)) and 5-FU IV (2,400 mg/m(2)) over 46 h plus leucovorin IV (400 mg/m(2)) over 2 h. Postoperative chemoradiotherapy was also administered to the patients when indicated. We retrospectively reviewed the patients who were treated with modified ECF.

RESULTS

The median disease-free survival (DFS) was 40.7 months and the 1-, 3- and 5-year DFS rates were 78.5, 55.7 and 44.6%, respectively. The most common grade 3-4 toxicities were hematological and gastrointestinal.

CONCLUSION

A modified ECF regimen may be an effective and convenient treatment with tolerable toxicities for the adjuvant treatment of gastric cancer. It may provide an alternative regimen to the standard ECF when a continuous ambulatory infusion pump is not feasible or not preferred by the patient.

Management strategies for locoregional recurrence in early-stage gastric cancer: retrospective analysis and comprehensive literature review

OBJECTIVE

To present a comprehensive account and literature review addressing the anatomical distribution, natural history, and management strategies for locoregional recurrence in early-stage gastric cancer (EGC).

PATIENTS AND METHODS

Retrospective chart review of patients presenting with EGC recurrence at King Hussein Cancer Center (Amman, Jordan) between July 2006 and May 2009. A literature review of publications addressing recurrence following surgery for EGC was undertaken via a systematic search of PUBMED database and National Comprehensive Cancer Network (NCCN) guideline updates.

RESULTS

Seventeen patients presented with EGC, three of whom (17.6%) were pathologically staged as T2N1 [1/33 lymph nodes (LNs)], T1N0, and T1N0 were afflicted by recurrence following R0 partial gastrectomy. Literature review yielded 18 studies specifically addressing recurrence in EGC. Several management strategies have been proposed for isolated recurrence following gastrectomy in EGC. NCCN clinical practice guideline updates do not take into consideration whether the recurrence is isolated or widespread and whether the initial stage is early or advanced.

CONCLUSIONS

While acknowledging the limitations of this study, including the small sample size and the short follow-up period, it appears clear that oncologic treatment is possible for EGC recurrence, particularly, in patients with isolated relapse. Guideline updates should differentiate between management strategies suitable for recurrence occurring in early versus advanced initial cancer stage.

Varying lymphadenectomies for gastric adenocarcinoma in the East compared with the west: effect on outcomes

There are notable differences in surgical approaches to gastric adenocarcinoma throughout the world, particularly in terms of the extent of lymphadenectomy (LAD). In high-incidence countries such as Japan and South Korea, more extensive (e.g., D2) lymphadenectomies are standard, and these surgeries are generally done by experienced surgeons with low morbidity and mortality. In countries such as the United States, where the incidence of gastric adenocarcinoma is 10-fold lower, the majority of patients are treated at nonreferral centers with less extensive (e.g., D1 or D0) lymphadenectomy. There is little disagreement among gastric cancer (GC) experts that the minimum lymphadenectomy that should be performed for gastric adenocarcinoma should be at least a D1 lymphadenectomy, and many of these experts recommend a D2 lymphadenectomy. More extensive lymphadenectomies provide better staging of patient disease and likely reduce locoregional recurrence rates. Two large, prospective randomized trials performed in the United Kingdom and the Netherlands in the 1990s failed to demonstrate a survival benefit of D2 over D1 lymphadenectomy, but these trials have been criticized for inadequate surgical training and high surgical morbidity and mortality rates (10% to 13%) in the D2 group. More recent studies have demonstrated that Western surgeons can be trained to perform D2 lymphadenectomies on Western patients with low morbidity and mortality. The 15-year follow-up of the Netherlands trial now demonstrates an improved disease-specific survival and locoregional recurrence in the D2 group. Retrospective analyses and one prospective, randomized trial suggest that there may be a survival benefit to more extensive lymphadenectomies when performed safely, but this assertion requires further validation.

Gastric adenocarcinoma surgery and adjuvant therapy

Gastric adenocarcinoma is one of the most common causes of death worldwide. Surgical resection remains the mainstay of therapy, offering the only chance for complete cure. Resection is based on the principles of obtaining adequate margins, with the extent of lymphadenectomy remaining controversial. Neoadjuvant and adjuvant therapies are used to reduce local recurrence and improve long-term survival. This article reviews the literature and provides a summary of surgical management options and neoadjuvant/adjuvant therapies for gastric adenocarcinoma.

Gastric cancer surgery: an American perspective on the current options and standards

Gastric cancer is prevalent globally, particularly in Asian countries such as Japan and Korea. While the prevalence of gastric cancer is not nearly as high in the United States (U.S.) as in Asia, the treatment armamentarium differs widely between regions. The role of surgery for gastric cancer in the U.S. has changed drastically over the last decade. While the natural history of gastric cancer seen in the U.S. markedly differs from that seen in Asia, the U.S. experience with endoscopic and minimally invasive techniques is beginning to parallel those seen in Japan and Korea. Minimally invasive surgery has truly come into the forefront of our surgical armamentarium, and its role, along with robotic and endoscopic approaches, remains to be defined as standard of care. At present, minimally invasive approaches appear to offer oncologically equivalent outcomes compared with standard open gastrectomy when performed by experienced surgeons. Extended lymphadenectomy does not appear to offer benefit with improved survival in our patient population, although sufficient lymph node sampling is imperative for adequate staging. Despite aggressive approaches to surgical resection for cure, the U.S. population tends to present with more advanced disease and have a worse prognosis than our Asian counterparts. Palliation with resection and possibly stent placement should be offered for improved quality of life in late-stage disease.

Gastric cancer growth control by BEZ235 in vivo does not correlate with PI3K/mTOR target inhibition but with [18F]FLT uptake

PURPOSE

In this study, we tested the antitumor activity of the dual phosphoinositide 3-kinase (PI3K)/mTOR inhibitor BEZ235 against gastric cancer in vitro and in vivo.

EXPERIMENTAL DESIGN

Gastric cancer cell lines (N87, MKN45, and MKN28) were incubated with BEZ235 and assessed for cell viability, cell cycle, and PI3K/mTOR target inhibition. In vivo, athymic nude mice were inoculated with N87, MKN28, or MKN45 cells and treated daily with BEZ235. 3'-Deoxy-3'-[(18)F]fluorothymidine ([(18)F]FLT) uptake was measured via small animal positron emission tomography (PET).

RESULTS

In vitro, BEZ235 dose dependently decreased the cell viability of gastric cancer cell lines. The antiproliferative activity of BEZ235 was linked to a G(1) cell-cycle arrest. In vivo, BEZ235 treatment resulted in PI3K/mTOR target inhibition as shown by dephosphorylation of AKT and S6 protein in all xenograft models. However, BEZ235 treatment only inhibited tumor growth of N87 xenografts, whereas no antitumor effect was observed in the MKN28 and MKN45 xenograft models. Sensitivity to BEZ235 in vivo correlated with downregulation of the proliferation marker thymidine kinase 1. Accordingly, [(18)F]FLT uptake was only significantly reduced in the BEZ235-sensitive N87 xenograft model as measured by PET.

CONCLUSION

In conclusion, in vivo sensitivity of gastric cancer xenografts to BEZ235 did not correlate with in vitro antiproliferative activity or in vivo PI3K/mTOR target inhibition by BEZ235. In contrast, [(18)F]FLT uptake was linked to BEZ235 in vivo sensitivity. Noninvasive [(18)F]FLT PET imaging might qualify as a novel marker for optimizing future clinical testing of dual PI3K/mTOR inhibitors.

An evidence-based review of the surgical treatment of gastric adenocarcinoma

The management of gastric adenocarcinoma continues to evolve. Chemotherapy is being increasingly used in both the neoadjuvant and adjuvant setting. Surgical resection of the stomach and regional lymph nodes remains the mainstay of potentially curative therapy, but significant regional differences persist in the surgical management. This review provides an update on the current literature regarding the preoperative evaluation and staging, extent of gastric resection, extent of lymph node resection, and adjuvant therapy for patients with gastric adenocarcinoma.

EGFR(s) in aging and carcinogenesis of the gastrointestinal tract

Cells of the gastrointestinal (GI) mucosa are subject to a constant process of renewal which, in normal adults, reflects a balance between the rates of cell production and cell loss. Detailed knowledge of these events is, therefore, essential for a better understanding of the normal aging processes as well as many GI diseases, particularly malignancy, that represent disorders of tissue growth. In general, many GI dysfunctions, including malignancy, increase with advancing age, and aging itself is associated with alterations in structural and functional integrity of the GI tract. Although the regulatory mechanisms for age-related increase in the incidence of GI-cancers are yet to be fully delineated, recent evidence suggests a role for epidermal growth family receptors and its family members {referred to as EGFR(s)} in the development and progression of carcinogenesis during aging. The present communication discusses the involvement of EGFR(s) in regulating events of GI cancers during advancing age and summarizes the current available therapeutics targeting these receptors. The current review also describes the effectiveness of ErbB inhibitors as well as combination therapies. Additionally, the involvement of GI stem cells in the development of the age-related rise in GI cancers is emphasized.

177Lu-immunotherapy of experimental peritoneal carcinomatosis shows comparable effectiveness to 213Bi-immunotherapy, but causes toxicity not observed with 213Bi

PURPOSE

(213)Bi-d9MAb-immunoconjugates targeting gastric cancer cells have effectively cured peritoneal carcinomatosis in a nude mouse model following intraperitoneal injection. Because the β-emitter (177)Lu has proven to be beneficial in targeted therapy, (177)Lu-d9MAb was investigated in this study in order to compare its therapeutic efficacy and toxicity with those of (213)Bi-d9MAb.

METHODS

Nude mice were inoculated intraperitoneally with HSC45-M2 gastric cancer cells expressing d9-E-cadherin and were treated intraperitoneally 1 or 8 days later with different activities of specific (177)Lu-d9MAb immunoconjugates targeting d9-E-cadherin or with nonspecific (177)Lu-d8MAb. Therapeutic efficacy was evaluated by monitoring survival for up to 250 days. For evaluation of toxicity, both biodistribution of (177)Lu-d9MAb and blood cell counts were determined at different time points and organs were examined histopathologically.

RESULTS

Treatment with (177)Lu-immunoconjugates (1.85, 7.4, 14.8 MBq) significantly prolonged survival. As expected, treatment on day 1 after tumour cell inoculation was more effective than treatment on day 8, and specific (177)Lu-d9MAb conjugates were superior to nonspecific (177)Lu-d8MAb. Treatment with 7.4 MBq of (177)Lu-d9MAb was most successful, with 90% of the animals surviving longer than 250 days. However, treatment with therapeutically effective activities of (177)Lu-d9MAb was not free of toxic side effects. In some animals lymphoblastic lymphoma, proliferative glomerulonephritis and hepatocarcinoma were seen but were not observed after treatment with (213)Bi-d9MAb at comparable therapeutic efficacy.

CONCLUSION

The therapeutic efficacy of (177)Lu-d9MAb conjugates in peritoneal carcinomatosis is impaired by toxic side effects. Because previous therapy with (213)Bi-d9MAb revealed comparable therapeutic efficacy without toxicity it should be preferred for the treatment of peritoneal carcinomatosis.

Gastric carcinoma in China: Current status and future perspectives (Review)

Gastric cancer is one of the most frequently occurring cancers in China, with an estimated 380,000 new cases each year, accounting for more than 40% of the worldwide annual cancer incidence. There is geographical clustering of the distribution of gastric cancer in China, with most of the high-risk areas being rural. D2 resection is the standard lymphadenectomy for curative resection in China, but more extensive lymphadenectomy is conducted for selected patients. Perioperative chemotherapy, postoperative chemotherapy or chemoradiotherapy can be combined with surgery. It remains uncertain which option is best, but if surgery is insufficient, adjuvant chemoradiotherapy is recommended. In the palliative setting, although there is no standard first-line chemotherapy, regimens based on taxane, oxaliplatin or capecitabine, or the epirubicin, cisplatin, 5-fluorouracil regimen and its modifications are the most common options selected by Chinese oncologists. Several studies to evaluate target therapy are ongoing, but it is too early to draw any conclusions. However, the development of target therapy is likely to become a milestone in the treatment of gastric cancer.

Recommendations on current approach to gastric cancer

The management of gastric cancer has been updated by the Grupo Español de Tratamiento de Tumores Digestivos (TTD). A multidisciplinary approach is essential in these patients including a precise diagnosis and staging and correct nutritional evaluation. For resectable disease, surgical resection remains the treatment mainstay and both perioperatory chemotherapy and postoperatory chemo-radiotherapy are considered standard complementary treatments. In advanced disease chemotherapy should always be considered. There are different reference schemes (TCF, XC, ECF, EXC) and the therapeutic option has to be individualised. Recently a phase III trial has shown a significant improvement in overall survival when trastuzumab is added to cisplatin-capecitabine or cisplatin-5-fluorouracil in patients with HER2+ advanced gastric cancer. Currently, there are several ongoing clinical trials evaluating the role of other new drugs against cellular targets. It would be desirable to incorporate biomarker studies in these trials in order to identify the best treatment for each patient.

Lymphadenectomy for gastric adenocarcinoma: should west meet east?

The extent of lymphadenectomy that should be performed for gastric adenocarcinoma has been a topic of persistent debate. In countries such as Japan and Korea, where the incidence of gastric adenocarcinoma is high, more extensive (e.g., D2) lymphadenectomies are routinely performed, usually by experienced surgeons with low morbidity and mortality. In western countries such as the U.S., where the incidence of gastric adenocarcinoma is tenfold lower, the performance of more extensive lymphadenectomies is generally limited to specialized centers, and quite possibly the majority of patients are treated at nonreferral centers with less than a D1 lymphadenectomy. There is little disagreement among gastric cancer experts that the minimum lymphadenectomy that should be performed for gastric adenocarcinoma should be at least a D1 lymphadenectomy. Two large, prospective randomized trials performed in the United Kingdom and the Netherlands failed to demonstrate a survival benefit of D2 over D1 lymphadenectomy, but these trials have been criticized for high surgical morbidity and mortality rates in the D2 group. More recent studies have demonstrated that western surgeons can be trained to perform D2 lymphadenectomies on western patients with low morbidity and mortality. Retrospective analyses and one prospective, randomized trial suggest that there may be some benefits to more extensive lymphadenectomies when performed safely, but this assertion requires further validation. This article provides an update on the current literature regarding the extent of lymphadenectomy for gastric adenocarcinoma.

Postoperative chemoradiotherapy in gastric cancer--a phase I-II study of radiotherapy with dose escalation of weekly cisplatin and daily capecitabine chemotherapy

BACKGROUND

Postoperative chemoradiotherapy with concurrent 5-fluorouracil improves gastric cancer outcome. We previously demonstrated that chemoradiotherapy with a more intensified--and therefore potentially more effective--schedule with daily cisplatin and oral capecitabine is feasible. Because such an intensive schedule requires an extensive logistic infrastructure which is not available in every hospital, we additionally investigated the tolerability of this combined regimen with weekly instead of daily cisplatin in a dose-escalation study.

PATIENTS AND METHODS

After R0 or R1 resection, treatment initiated with capecitabine 1000 mg/m(2) b.i.d. for 2 weeks and 1-week rest. Subsequently, patients received capecitabine (575-650 mg/m(2) orally b.i.d., 5 days/week) and cisplatin (20-25 mg/m(2) i.v., once weekly) according to a predefined dose-escalation schedule concurrent with radiation. Radiotherapy was given to a fixed total dose of 45 Gy in 25 fractions.

RESULTS

Thirty-one patients were eligible and started treatment. During chemoradiotherapy, seven patients developed 10 items of grade III and one episode of grade IV (mainly hematological) toxicity (National Cancer Institute-Common Toxicity Criteria version 3.0). The maximum tolerable dose was determined to be for cisplatin 20 mg/m(2) i.v. weekly and for capecitabine 575 mg/m(2) b.i.d. orally.

CONCLUSIONS

This phase I-II study demonstrated that postoperative chemoradiotherapy with weekly cisplatin and daily capecitabine is feasible in gastric cancer at the defined dose level. This schedule is currently being tested as the experimental arm in a phase III multicenter study (CRITICS: chemoradiotherapy after induction chemotherapy in cancer of the stomach; Clinicaltrials.gov NCT 00407186).

Gastric cancer

Gastric cancer is the second most frequent cause of cancer death worldwide, although much geographical variation in incidence exists. Prevention and personalised treatment are regarded as the best options to reduce gastric cancer mortality rates. Prevention strategies should be based on specific risk profiles, including Helicobacter pylori genotype, host gene polymorphisms, presence of precursor lesions, and environmental factors. Although adequate surgery remains the cornerstone of gastric cancer treatment, this single modality treatment seems to have reached its maximum achievable effect for local control and survival. Minimally invasive techniques can be used for treatment of early gastric cancers. Achievement of locoregional control for advanced disease remains very difficult. Extended resections that are standard practice in some Asian countries have not been shown to be as effective in other developed countries. We present an update of the incidence, causes, pathology, and treatment of gastric cancer, consisting of surgery, new strategies with neoadjuvant and adjuvant chemotherapy or radiotherapy, or both, novel treatment strategies using gene signatures, and the effect of caseload on patient outcomes.

Outcome in relation to numbers of nodes harvested in lymph node-positive gastric cancer

AIMS

We conducted a retrospective case-control study to compare the prognostic differences of lymph node-positive gastric cancer patients between dissected lymph nodes (DLNs) <15 group and DLNs > or =15 group.

METHODS

A retrospective study of 323 lymph node-positive gastric patients who underwent potentially curative resection for gastric cancer was analyzed to identify the prognostic differences between DLNs <15 group and DLNs > or =15 group. Of these patients, 49 patients with <15 DLNs were matched with 147 patients with > or =15 DLNs according to gender, age, location of primary tumor, and type of gastrectomy.

RESULTS

Patients with n1 lymph node metastasis (according to JCGC), serosal involvement, ratio of positive lymph nodes less than 25%, or without adjuvant chemotherapy in > or =15 DLN group had comparatively longer median survival than patients with homologous clinicopathologic variables in <15 DLN group, respectively. Patients with n1 stage lymph node metastasis, serosal involvement, non-intestinal Lauren classification, or without adjuvant chemotherapy in <15 DLN group had higher recurrence rate than patients with homologous clinicopathologic variables in > or =15 DLN group, respectively. In addition, we demonstrated that patients with more than n1 stage lymph node metastasis in <15 DLN group had higher rate of peritoneal dissemination than those with more than n1 lymph node metastasis in > or =15 DLN group.

CONCLUSIONS

DNL > or =15 was an important factor to improve the prognosis of lymph node-positive gastric cancer patients after potential curative resection.

Gastric cancer

Gastric cancer is the second most frequent cause of cancer death worldwide, although much geographical variation in incidence exists. Prevention and personalised treatment are regarded as the best options to reduce gastric cancer mortality rates. Prevention strategies should be based on specific risk profiles, including Helicobacter pylori genotype, host gene polymorphisms, presence of precursor lesions, and environmental factors. Although adequate surgery remains the cornerstone of gastric cancer treatment, this single modality treatment seems to have reached its maximum achievable effect for local control and survival. Minimally invasive techniques can be used for treatment of early gastric cancers. Achievement of locoregional control for advanced disease remains very difficult. Extended resections that are standard practice in some Asian countries have not been shown to be as effective in other developed countries. We present an update of the incidence, causes, pathology, and treatment of gastric cancer, consisting of surgery, new strategies with neoadjuvant and adjuvant chemotherapy or radiotherapy, or both, novel treatment strategies using gene signatures, and the effect of caseload on patient outcomes.

The potential of proton beam radiation therapy in gastrointestinal cancer

A group of Swedish oncologists and hospital physicists have estimated the number of patients in Sweden suitable for proton beam therapy. The estimations have been based on current statistics of tumour incidence, number of patients potentially eligible for radiation treatment, scientific support from clinical trials and model dose planning studies and knowledge of the dose-response relations of different tumours and normal tissues. In gastrointestinal cancers, it is assessed that at least 345 patients, mainly non-resectable rectal cancers, oesophageal and liver cancers, are eligible. Great uncertainties do however exist both in the number of patients with gastrointestinal cancers suitable for radiation therapy, and in the proportion of those where proton beams may give sufficiently better results.

VEGF kinase inhibitors: how do they cause hypertension?

Neoangiogenesis is a critical phenomenon enabling the growth and metastasis of tumors, and inhibitors of neoangiogenesis have been recently added to the armamentarium of anticancer therapies available for clinical use. Dysregulated signaling through the vascular endothelial growth factor (VEGF) pathway has been implicated as a key mediator of neoangiogenesis in tumors. Agents that block signaling through the VEGF pathway demonstrated tumor shrinkage in preclinical models and were therefore developed as anticancer therapies for use in humans. VEGF kinase inhibitors are being used in the treatment of a wide variety of cancers, and recent studies have shown that patients will likely require long-term treatment with these agents. Hypertension has emerged as a frequent side effect associated with agents that block signaling through the VEGF pathway. A thorough understanding of the mechanisms underlying hypertension is crucial to developing appropriate therapeutic strategies for treating hypertension associated with VEGF kinase inhibitors. Several recent studies have advanced our understanding of the pathophysiology of hypertension associated with VEGF kinase inhibitors and will be the subject of this review.

[Extending the limits of lymphadenectomy during radical cystectomy: pitfalls in the interpretation of contemporary study results]

The optimal extent of lymphadenectomy performed during radical cystectomy for transitional cell carcinoma of the bladder is currently under intensive debate. Extending the limits of lymphadenectomy has been hypothesized to add further diagnostic and therapeutic benefit. However, our current knowledge is based exclusively on results from retrospective studies that are hampered by several statistical shortcomings. This article provides a critical analysis of the contemporary data on the subject and outlines typical statistical pitfalls that must be considered when interpreting such research results.

Multidisciplinary management of gastric and gastroesophageal cancers

Carcinomas of the stomach and gastroesophageal junction are among the five top leading cancer types worldwide. In spite of radical surgical R0 resections being the basis of cure of gastric cancer, surgery alone provides long-term survival in only 30% of patients with advanced International Union Against Cancer (UICC) stages in Western countries because of the high risk of recurrence and metachronous metastases. However, recent large phase-III studies improved the diagnostic and therapeutic options in gastric cancers, indicating a more multidisciplinary management of the disease. Multimodal strategies combining different neoadjuvant and/or adjuvant protocols have clearly improved the gastric cancer prognosis when combined with surgery with curative intention. In particular, the perioperative (neoadjuvant, adjuvant) chemotherapy is now a well-established new standard of care for advanced tumors. Adjuvant therapy alone should be carefully discussed after surgical resection, mainly in individual patients with large lymph node positive tumors when neoadjuvant therapy could not be done. The palliative treatment options have also been remarkably improved with new chemotherapeutic agents and will further be enhanced with targeted therapies such as different monoclonal antibodies. This article reviews the most relevant literature on the multidisciplinary management of gastric and gastroesophageal cancer, and discusses future strategies to improve locoregional failures.

An appraisal of radiation therapy techniques for adjuvant and neoadjuvant therapy in gastric cancer

In last few years, adjuvant post-operative radiotherapy and occasionally preoperative irradiation combined with chemotherapy are considered as effective practices to improve disease control and survival in gastric cancer. Yet, chemoradiotherapy result in severe toxicities and radiotherapy practice is a significant contributor. For a recommended median dose of 45 Gy to the treatment volume of stomach and surrounding lymphnode regions, considerable doses are likely to be delivered to liver, kidneys and spinal cord. Few literatures and texts state about the radiotherapy techniques, with recent emphasis on conformal (3-D CRT) or intensity-modulated radiotherapy (IMRT). However, these facilities are not uniformly available in most developing countries where stomach cancer is common. This is a report on practical aspects of radiotherapy techniques and planning which can be utilised as per available settings of a radiotherapy department.

Cancer of the esophagus and stomach

Upper gastrointestinal tumors involving the esophagus and the stomach are a serious public health problem worldwide. The West has seen a dramatic increase in the incidence of gastroesophageal cancers in the past 2 decades. Although Barrett esophagus has been well characterized, the exact pathway to developing frank malignancy remains undefined. Current treatments for locoregional disease include surgery, chemotherapy, radiation therapy, or some combination thereof. Clinical trials are currently investigating biologic agents that target signaling pathways in carcinogenesis. Whether this research translates into an improved therapeutic index remains to be seen. This review provides a comprehensive update to physicians and residents who contribute to the care of these patients. Studies in the English language were identified searching PubMed (January 1, 1980, through February 29, 2008) using the terms esophagus, gastric, carcinoma, adenocarcinoma, squamous cell, radiation, chemotherapy, surgery, esophagectomy, and targeted therapy.

Using Molecular Biology to Develop Drugs for Renal Cell Carcinoma

BACKGROUND: Renal cell carcinoma is a disease marked by a unique biology which has governed it's long history of poor response to conventional cancer treatments. The discovery of the signaling pathway activated as a result of inappropriate constitutive activation of the hypoxia inducible factors (HIF), transcription factors physiologically and transiently stabilized in response to low oxygen, has provided a primary opportunity to devise treatment strategies to target this oncogenic pathway. OBJECTIVE: A review of the molecular pathogenesis of renal cell cancer as well as molecularly targeted therapies, both those currently available and those in development, will be provided. In addition, trials involving combination or sequential targeted therapy are discussed. METHODS: A detailed review of the literature describing the molecular biology of renal cell cancer and novel therapies was performed and summarized. RESULTS/CONCLUSION: Therapeutics targeting angiogenesis have provided the first class of agents which provide clinical benefit in a large majority of patients and heralded renal cell carcinoma as a solid tumor paradigm for the development of novel therapeutics. Multiple strategies targeting this pathway and now other identified pathways in renal cell carcinoma provide numerous potential opportunities to make major improvements in treating this historically devastating cancer.

The prognostic value of N-ratio in patients with gastric cancer: validation in a large, multicenter series

AIMS

The proportion between metastatic and examined lymph nodes (N-ratio) has been proposed as an independent prognostic factor in patients with gastric cancer. In the present work we validated the reliability of N-ratio in a large, multicenter series.

PATIENTS AND METHODS

We retrospectively reviewed the data of 1853 patients who underwent radical resection for gastric carcinoma. Survival of patients with >15 (Group-1, n=1421) and those with < or =15 (Group-2, n=432) lymph nodes examined was separately analyzed in order to evaluate the influence of lymph node dissection on disease staging. N-ratio categories (N-ratio 0, 0%; N-ratio 1, 1-9%; N-ratio 2, 10-25%; N-ratio 3, >25%) were determined by the best cut-off approach.

RESULTS

At multivariate analysis, N-ratio (but not TNM N-category) was retained as an independent prognostic factor both in Group-1 and Group-2 (HR for N-ratio 1, N-ratio 2 and N-ratio 3=1.67, 2.96 and 6.59, and 1.56, 2.68 and 4.28, respectively). After a median follow-up of 45.5 months, the 5-year overall survival rates of TNM N0, N1 and N2 patients were significantly different in Group-1 vs Group-2. This was not the case when adopting the N-ratio classification, suggesting that a low number of excised lymph nodes can lead to patients being understaged using the N-category, but not N-ratio. Moreover, N-ratio identified subsets of patients with significantly different survival rates within TNM N1 and N2 categories in both groups.

CONCLUSIONS

N-ratio is a simple and reproducible prognostic tool that can stratify patients with gastric cancer, including those cases with limited lymph node dissection. These data support the rationale to propose the implementation of N-ratio into the current TNM staging system.

Improving the prognosis of patients after radical cystectomy. Part I: the role of lymph node dissection

The first two reviews are from the same unit in Germany and describe the well-known but still much discussed ways of improving the prognosis of patients undergoing cystectomy for bladder cancer. The authors review the roles of lymph node dissection and perioperative chemotherapy, and draw conclusions which will be of help for patients having this form of therapy. In a further review, authors from Egypt debate the requirement for a refluxing or non-refluxing uretero-ileal anastomosis in low-pressure reservoirs, drawing on their extensive experience in this field. The optimum treatment for patients with muscle-invasive bladder cancer remains a matter of intense debate; some authors still question the role of radical cystectomy (RC) per se, as it can be a potentially mutilating procedure with subsequent impairment in quality of life. However, the impairment has not been investigated using validated quality-of-life studies. By contrast, it is commonly accepted that no alternative treatment yields similar long-term survival data to RC. However, survival rates after RC are far from satisfying, particularly for patients with >/= pT3 and/or pN+ disease. Therefore, various strategies were introduced to improve survival in these patients, i.e. extension of lymph node dissection during radical surgery and perioperative chemotherapy. Both strategies are analysed and discussed in two mini-reviews, based on data from current publications and from theoretical considerations.

Postoperative chemoradiotherapy in gastric cancer -- a Phase I/II dose-finding study of radiotherapy with dose escalation of cisplatin and capecitabine chemotherapy

We hypothesised that gastric cancer outcome could be improved with more effective and intensified postoperative chemoradiotherapy. This phase I/II study was performed to determine the maximal tolerated dose (MTD) and toxicity profile of postoperative radiotherapy with concurrent daily cisplatin and capecitabine. Patients were treated with capecitabine 1000 mg m⁻² twice a day (b.i.d.) for 2 weeks. Subsequently, patients received capecitabine (250–650 mg m⁻² orally b.i.d., 5 days week⁻¹) and cisplatin (3–6 mg m⁻² i.v., 5 days week⁻¹) according to an alternating dose-escalation schedule. Radiotherapy was given to a total dose of 45 Gy in 25 fractions. Thirty-one patients completed treatment. During chemoradiotherapy, eight patients developed nine items of grade III and one episode of grade IV (mainly haematological) toxicity. The MTD was determined to be cisplatin 5 mg m⁻² i.v. and capecitabine 650 mg m⁻² b.i.d. orally. This phase I/II study demonstrated that chemoradiotherapy with daily cisplatin and capecitabine is feasible in postoperative gastric cancer at the defined dose level and is currently being tested in a phase III multicenter study.

Self-reported experience and outcomes of care among stomach cancer patients at a median follow-up time of 27 months from diagnosis

GOALS OF WORK

We aimed to identify clinical experiences associated with outcomes of care among stomach cancer patients.

MATERIALS AND METHODS

Four hundred thirty-two patients who had a diagnosis of stage I-III stomach cancer from 2001 through 2002 from two hospitals in South Korea responded to a survey questionnaire including sociodemographic and clinical data, information about care experiences, satisfaction with care, and quality of life (QOL).

MAIN RESULTS

Involvement in decision making [adjusted odds ratio (aOR) = 1.81; 95% confidence interval (CI), 1.13 to 2.89] and reflection of patients' opinions in treatment decisions (aOR = 2.54; 95% CI, 1.65 to 3.93) were associated with decision satisfaction. The factors associated with willingness to choose the same treatment over again were involvement in decision making (aOR = 2.37; 95% CI, 1.53 to 3.68) and no treatment toxicity (aOR = 0.50; 95% CI, 0.29 to 0.87). Involvement in decision making, reflection of patients' opinions in treatment decisions, and treatment toxicity were associated with some functioning subscales of QOL (p < 0.05). Regular follow-up, however, was associated with poor social functioning.

CONCLUSIONS

Quality improvement efforts for stomach cancer patients should focus not only on the quality of primary tumor therapy but also on how patients experience their care, such as patient-centered decision making, experience of treatment toxicity, and regular follow-up.

A phase I-II study of postoperative capecitabine-based chemoradiotherapy in gastric cancer

BACKGROUND

The Intergroup 0116 randomized study showed that postoperative 5-fluorouracil-based chemoradiotherapy improved locoregional control and overall survival in patients with gastric cancer. We hypothesized that these results could be improved further by using a more effective, intensified, and convenient chemotherapy schedule. Therefore, this Phase I-II dose-escalation study was performed to determine the maximal tolerated dose and toxicity profile of postoperative radiotherapy combined with concurrent capecitabine.

PATIENTS AND METHODS

After recovery from surgery for adenocarcinoma of the gastroesophageal junction or stomach, all patients were treated with capecitabine monotherapy, 1,000 mg/m2 twice daily for 2 weeks. After a 1-week treatment-free interval, patients received capecitabine (650-1,000 mg/m2 orally twice daily 5 days/week) in a dose-escalation schedule combined with radiotherapy on weekdays for 5 weeks. Radiotherapy was delivered to a total dose of 45 Gy in 25 fractions to the gastric bed, anastomoses, and regional lymph nodes.

RESULTS

Sixty-six patients were treated accordingly. Two patients went off study before or shortly after the start of chemoradiotherapy because of progressive disease. Therefore, 64 patients completed treatment as planned. During the chemoradiotherapy phase, 4 patients developed four items of Grade III dose-limiting toxicity (3 patients in Dose Level II and 1 patient in Dose Level IV). The predefined highest dose of capecitabine, 1,000 mg/m2 twice daily orally, was tolerated well and, therefore, considered safe for further clinical evaluation.

CONCLUSIONS

This Phase I-II study shows that intensified chemoradiotherapy with daily capecitabine is feasible in postoperative patients with gastroesophageal junction and gastric cancer.

Adjuvant treatment of high-risk, radically resected gastric cancer patients with 5-fluorouracil, leucovorin, cisplatin, and epidoxorubicin in a randomized controlled trial

BACKGROUND

Promising findings obtained using a weekly regimen of 5-fluorouracil (5-FU), epidoxorubicin, leucovorin (LV), and cisplatin (PELFw) to treat locally advanced and metastatic gastric cancer prompted the Italian Group for the Study of Digestive Tract Cancer (GISCAD) to investigate the efficacy of this regimen as adjuvant treatment for high-risk radically resected gastric cancer patients.

METHODS

From January 1998 to January 2003, 400 gastric cancer patients at high risk for recurrence including patients with serosal invasion (stage pT3 N0) and/or lymph node metastasis (stage pT2 or pT3 N1, N2, or N3), were enrolled in a trial of adjuvant chemotherapies; 201 patients were randomly assigned to receive the PELFw regimen, consisting of eight weekly administrations of cisplatin (40 mg/m2), LV (250 mg/m2), epidoxorubicin (35 mg/m2), 5-FU (500 mg/m2), and glutathione (1.5 g/m2) with the support of filgrastim, and 196 patients were assigned to a regimen consisting of six monthly administrations of a 5-day course of 5-FU (375 mg/m2 daily) and LV (20 mg/m2 daily, 5-FU/LV). Disease-free and overall survival were estimated and compared between arms using hazard ratios (HRs) and Kaplan-Meier estimates. All statistical tests were two-sided.

RESULTS

The 5-year survival rates were 52% in the PELFw arm and 50% in the 5-FU/LV arm. Compared with the 5-FU/LV regimen, the PELFw regimen did not reduce the risk of death (HR = 0.95, 95% confidence interval [CI] = 0.70 to 1.29) or relapse (HR = 0.98, 95% CI = 0.75 to 1.29). Less than 10% of patients in either arm experienced a grade 3 or 4 toxic episode. Neutropenia (occurring more often in the PELFw arm) and diarrhea and mucositis (more prevalent in the 5-FU/LV arm) were the most common serious side effects. Nevertheless, only 19 patients (9.4%) completed the treatment in the PELFw arm and 85 (43%) patients completed the treatment in the 5-FU/LV arm.

CONCLUSIONS

Our study found no benefit from an intensive weekly chemotherapy in gastric cancer. The extent of toxicity experienced by the patients in the adjuvant setting suggests that, in gastric cancer, chemotherapy may be more safely administered preoperatively.

The ratio between metastatic and examined lymph nodes (N ratio) is an independent prognostic factor in gastric cancer regardless of the type of lymphadenectomy: results from an Italian multicentric study in 1853 patients

PURPOSE

To investigate whether the ratio between metastatic and examined lymph nodes (N ratio) is a better prognostic factor as compared with traditional staging systems in patients with gastric cancer regardless of the extension of lymph node dissection.

PATIENTS & METHODS

We retrospectively reviewed the data of 1853 patients who underwent radical resection for gastric carcinoma at 6 Italian centers. Patients with >15 (group 1, n = 1421) and those with 25%) were determined by the best cut-off approach.

RESULTS

After a median follow-up of 45.5 months (range, 4-182 months), the 5-year overall survival of N0, N1, and N2 patients of group 1 versus group 2 was 83.4% versus 74.2% (P = 0.0026), 54.3% versus 44.3% (P = 0.018), and 32.7% versus 14.7% (P = 0.004), respectively, suggesting that a low number of excised lymph nodes can lead to the understaging of patients. N ratio identified subsets of patients with significantly different survival rates within N1 and N2 stages in both groups. At multivariate analysis, the N ratio (but not N stage) was retained as an independent prognostic factor both in group 1 and group 2 (HR for N ratio 1, N ratio 2, and N ratio 3 = 1.67, 2.96, and 6.59, and 1.56, 2.68, and 4.28, respectively). In our series, the implementation of N ratio led to the identification of subgroups of patients prognostically more homogeneous than those classified by the TNM system.

CONCLUSION

N ratio is a simple and reproducible prognostic tool that can stratify patients with gastric cancer also in case of limited lymph node dissection. These data may represent the rational for improving the prognostic power of current UICC TNM staging system and ultimately the selection of patients who may most benefit from adjuvant treatments.

Gastric distension by ingesting food is useful in the evaluation of primary gastric cancer by FDG PET

Gastric carcinoma is the second leading cause of cancer-related death worldwide. Detection and surgical resection of gastric cancer in the early stage provides the only hope for improved survival in patients with gastric cancer. Positron emission tomography (PET) with F-18 2-deoxy-2-fluoro-D-glucose (FDG) has been shown to be essential in the evaluation of a variety of malignancies. However, conventional FDG PET has limited value for detecting a primary tumor of the stomach, mostly because of the relatively high levels of physiological uptake by the contracted stomach. We report 3 cases of primary gastric carcinomas detected successfully by FDG PET after the ingestion of food. The PET images of the stomach after ingesting food were compared with the routine fasting-state whole-body PET images for each patient. When the stomach was distended by food, the malignant lesions were more discernible. These cases indicate that gastric distension by ingesting food may be a simple method that can help to detect a primary gastric malignancy by FDG PET.

Gastric adenocarcinoma: reduction of perioperative mortality by avoidance of nontherapeutic laparotomy

National trends indicate a longstanding decline in gastric adenocarcinoma due presumably to a decreasing prevalence of Helicobacter pylori infection. Nonetheless, surgical outcomes continue to include relatively high morbidity and mortality rates owing to the advanced stage of disease encountered. We hypothesize that recent immigration patterns are responsible for a leveling off or even reversal of the declining incidence of gastric cancer associated with H. pylori infection. Furthermore, advances in preoperative tumor staging and nonoperative palliation currently permit better patient selection for operation with lower perioperative morbidity and mortality. A retrospective review of a consecutive case series at a public teaching hospital located in an area of high immigration was conducted that included all patients presenting, from 1995 through 2004, with gastric adenocarcinoma. For time comparison purposes, patients were divided into early (1995-1999) and recent (2000-2004) periods. There was no decline in the frequency of gastric adenocarcinoma among the study population over the 10 years. A total of 260 patients were treated of whom 137 (53%) underwent operation. The operation rate decreased and the gastric resection rate increased from the early period to the recent period as fewer incurable advanced stage (M1) patients underwent exploratory laparotomy and were palliated by nonoperative means. Perioperative morbidity and mortality rates also declined over time. Of the four total perioperative deaths, two followed 11 nontherapeutic laparotomies (18% mortality), whereas the only two additional deaths followed 122 curative or palliative laparotomies (2% mortality) (p = 0.034). We conclude that in an area of high immigration there has been no decline in gastric adenocarcinoma rates over the past decade, and the marked reduction in perioperative mortality was due to near elimination of nontherapeutic laparotomy.