Surgical complications in gastric cancer patients preoperatively treated with chemotherapy: their risk factors and clinical relevance

Comparison of short- and long-term outcomes of robotic versus laparoscopic gastrectomy for locally advanced gastric cancer after neoadjuvant therapy: a high-volume center retrospective study with propensity score matching

BACKGROUND

Although neoadjuvant therapy (NAT) for advanced gastric cancer (AGC) can benefit patient survival, few studies have compared the short- and long-term outcomes of robotic and laparoscopic gastrectomy for AGC after NAT.

METHODS

The clinical data of 321 AGC patients who received NATs and who underwent robotic gastrectomy (RG, n = 109) or laparoscopic gastrectomy (LG, n = 212) between May 2017 and September 2022 were collected and analyzed retrospectively at our center. After propensity score matching (PSM) for 1:1 matching to eliminate bias, both groups had 106 cases. Short-term clinical outcomes and long-term survival-related indicators were compared between the two groups of patients.

RESULTS

A total of 212 patients were included in the groups after matching. There were fewer overall complications (13.2% vs. 28.3%, P = 0.007) and surgical complications (8.5% vs. 17.9%, P = 0.043) in the RG group than in the LG group. Compared with the LG group, the RG group had more harvested overall lymph nodes (35.25 ± 4.99 vs. 31.45 ± 6.31, P < 0.001) and more suprapancreatic lymph nodes (13.12 ± 4.38 vs. 10.05 ± 4.13, P < 0.001). Patients in the RG group had significantly shorter surgery times (217.62 ± 47.49 vs. 267.25 ± 70.68, P < 0.001) and less blood loss (46.51 ± 27.02 vs. 70.75 ± 37.25, P < 0.001) than patients in the LG group. The RG group had significantly faster bowel function recovery, earlier liquid diet, and shorter hospital stay. Compared with LG, RG had a better 3-year RFS (75.5% vs. 62.3%, P = 0.017).

CONCLUSION

Compared with laparoscopic surgery, robotic surgery significantly increased the number of lymph node dissected, reduced intraoperative blood loss, and postoperative surgical complications rate. Although RG did not statistically improve 3-year overall survival, there was a significant improvement in RFS and could be an alternative surgical method for GC patients after NAC.

Neoadjuvant therapy with immune checkpoint inhibitors in combination with chemotherapy vs . chemotherapy alone in HER2(-) locally advanced gastric cancer: A propensity score-matched cohort study

BACKGROUND

This study aims to compare the efficacy between neoadjuvant immune checkpoint inhibitors (ICIs) plus chemotherapy vs . chemotherapy, and neoadjuvant triplet vs . doublet chemotherapeutic regimens in locally advanced gastric/esophagogastric junction cancer (LAGC).

METHODS

We included LAGC patients from 47 hospitals in China's National Cancer Information Database (NCID) from January 2019 to December 2022. Using propensity score matching (PSM), we retrospectively analyzed the efficacy between neoadjuvant ICIs plus chemotherapy vs . chemotherapy alone, and neoadjuvant triplet vs . doublet chemotherapeutic regimens. The primary study result was the pathologic complete response (pCR) rate. The secondary study results were disease-free survival (DFS) and overall survival (OS).

RESULTS

A total of 1205 LAGC patients were included. After PSM, the ICIs plus chemotherapy and the chemotherapy cohorts had 184 patients each, while the doublet and triplet chemotherapy cohorts had 246 patients each. The pCR rate (14.13% vs . 7.61%, χ2 = 4.039, P = 0.044), and the 2-year (77.60% vs . 61.02%, HR = 0.67, 95% con-fidence interval [CI] 0.43-0.98, P = 0.048) and 3-year (70.55% vs . 61.02%, HR = 0.58, 95% CI 0.32-0.93, P = 0.048) DFS rates in the ICIs plus chemotherapy cohort were improved compared to those in the chemotherapy cohort. No significant increase was observed in the OS rates at both 1 year and 2 years. The pCR rates, DFS rates at 1-3 years, and OS rates at 1-2 years did not differ significantly between the doublet and triplet cohorts, respectively. No differences were observed in postoperative complications between any of the group comparisons.

CONCLUSIONS

Neoadjuvant ICIs plus chemotherapy improved the pCR rate and 2-3 years DFS rates of LAGC compared to chemotherapy alone, but whether short-term benefit could translate into long-term efficacy is unclear. The triplet regimen was not superior to the doublet regimen in terms of efficacy. The safety after surgery was similar between either ICIs plus chemotherapy and chemotherapy or the triplet and the doublet regimen.

Safety and feasibility of laparoscopic stomach-partitioning gastrojejunostomy combined with neoadjuvant chemotherapy followed by minimally invasive gastrectomy for resectable gastric cancer with gastric outlet obstruction

BACKGROUND

Advanced gastric cancer with gastric outlet obstruction (GOO) causes malnutrition and medication adherence issues, leading to a poor prognosis. We developed a novel multimodal, less invasive treatment approach for gastric cancer patients with symptomatic GOO: laparoscopic stomach-partitioning gastrojejunostomy (LSPGJ) combined with neoadjuvant chemotherapy (NAC), followed by minimally invasive gastrectomy with reuse of gastrojejunostomy. This study is a retrospective analysis of the safety and feasibility of our treatment strategy.

METHODS

In this single-institution retrospective study, we enrolled 54 patients (NAC group, n = 26; upfront gastrectomy group, n = 28) who achieved R0 resection through a minimally invasive approach between 2007 and 2020 and evaluated their short- and long-term outcomes.

RESULTS

After LSPGJ, the Gastric Outlet Obstruction Scoring System score significantly improved (p < 0.001). The median relative dose intensity of NAC was 88.2%. Regarding short-term outcomes, there were no differences in postoperative complications, length of postsurgical hospital stay, and adjuvant chemotherapy administration. Although overall survival and relapse-free survival showed trends toward improvement in the NAC group, these differences were not statistically significant. The cumulative incidence curve for recurrence in the NAC group was significantly lower than that of the upfront gastrectomy group (p = 0.041). Recurrence and hematogenous metastasis were significantly lower in the NAC group (p = 0.031 and 0.041, respectively) than in the upfront gastrectomy group. A forest plot revealed that NAC yielded favorable outcomes, particularly for patients with a body mass index (BMI) < 18.5 kg/m2, cT4, or cN1.

CONCLUSIONS

LSPGJ combined with NAC followed by minimally invasive gastrectomy was a safe and feasible treatment strategy for patients with advanced gastric cancer with symptomatic GOO. This procedure may contribute to the early recovery of oral intake and help maintain NAC dose intensity, potentially improving prognosis, particularly for patients with low BMI and advanced-stage disease.

Adjuvant chemotherapy versus preoperative chemotherapy for gastric cancer treated with curative-intent resection: A propensity score-matched analysis

BACKGROUND

Multimodal therapy (MMT), comprising surgery alongside perioperative chemotherapy (PCMT) or adjuvant chemotherapy (ACMT), has demonstrated improve in survival compared with surgery alone for advanced gastric cancer (GC). However, the moment of administering chemotherapy for GC is still a matter of debate. This study aimed to compare PCMT and ACMT in patients with locally advanced GC.

METHOD

We included all gastric adenocarcinoma treated with chemotherapy and curative-intent resection. Using propensity score matching (PSM), patients who received PCMT were matched with patients undergoing ACMT for 10 pretreatment variables.

RESULTS

Among the 552 patients with indication for MMT, 377 (68.3%) received combining chemotherapy (CMT): 116 (30.8%) PCMT and 261 (69.2%) ACMT. After PSM, 109 patients were matched in each group. All variables assigned in the score were well matched and both groups became equivalent. Patients receiving PCMT had less angiolymphatic and perineural invasion, less advanced pT, pN and pTNM stage than ACMT group (p < 0.001 for all). There was no difference in the postoperative complication rate between both groups (p = 0.551). After the matching, disease-free survival (DFS) and overall survival (OS) became similar between PCMT and ACMT groups (DFS: 51.4% vs. 46.9%, p = 0.882, respectively; OS: 54.3% vs. 48.7%, p = 0.638, respectively).

CONCLUSION

After controlling for pretreatments characteristics, there was no significant difference in survival between GC patients who underwent perioperative and adjuvant CMT. PCMT did not result in an increase in survival, but it provides a decrease in the stage of the disease, with no difference in surgical outcomes.

Preoperative nutritional status and postoperative health outcomes in older adults undergoing spine surgery: Electronic health records analysis

AIM

To examine whether a high nutritional risk status, assessed via the Geriatric Nutritional Risk Index (GNRI), is independently associated with postoperative health outcomes, including unplanned intensive care unit (ICU) admissions, infectious complications, and prolonged length of stay in older patients undergoing spine surgery.

METHODS

We conducted a retrospective descriptive study analyzing electronic health records from a tertiary hospital, including data from 1,014 patients aged ≥70 undergoing elective spine surgery between February 2013 and March 2023.

RESULTS

High nutritional risk patients had significantly higher odds of unplanned ICU admission, infectious complications, and prolonged length of stay compared to low-risk patients. For each one-point increase in GNRI, there was a significant 0.91- and 0.95-fold decrease in the odds of unplanned ICU admission and infectious complications, respectively.

CONCLUSION

GNRI screening in older patients before spine surgery may have potential to identify those at elevated risk for postoperative adverse outcomes.

Laparoscopic versus open gastrectomy for locally advanced gastric cancer after neoadjuvant chemotherapy: a comprehensive contrastive analysis with propensity score matching

BACKGROUND

Laparoscopic gastrectomy (LG) is increasingly applied in locally advanced gastric cancer (LAGC) after neoadjuvant chemotherapy (NC). However, there is no study to comprehensively evaluate the clinicopathological, prognostic, and laboratory data such as nutrition, immune, inflammation-associated indexes, and tumor markers between LG and open gastrectomy (OG) for LAGC following NC.

METHODS

The clinicopathological, prognostic, and laboratory data of LAGC patients with clinical stage of cT2-4aN1-3M0 who underwent gastrectomy after NC were retrospectively collected. The effects of LG and OG were compared after propensity score matching (PSM).

RESULTS

This study enrolled 148 cases, of which 110 cases were included after PSM. The LG group had a shorter length of incision (P < 0.001) and was superior to OG group in terms of blood loss (P < 0.001), postoperative first flatus time (P < 0.001), and postoperative first liquid diet time (P = 0.004). No significant difference was found in postoperative complications (P = 0.482). Laboratory results showed that LG group had less reduced red blood cells (P = 0.039), hemoglobin (P = 0.018), prealbumin (P = 0.010) in 3 days after surgery, and less reduced albumin in 1 day (P = 0.029), 3 days (P = 0.015), and 7 days (P = 0.035) after surgery than the OG group. The systemic immune-inflammation index and systemic inflammatory response index were not significantly different between the two groups. As for oncological outcomes, there were no significant differences in postoperative tumor markers of CEA (P = 0.791), CA199 (P = 0.499), and CA724 (P = 0.378). The 5-year relapse-free survival rates (P = 0.446) were 46.9% and 43.3% in the LG and OG groups, with the 5-year overall survival rates (P = 0.742) being 46.7% and 52.1%, respectively; the differences were not statistically significant. Multivariate Cox regression analysis revealed that tumor size ≥ 4 cm (P = 0.021) and the absence of postoperative adjuvant chemotherapy (P = 0.012) were independent risk factors for overall survival.

CONCLUSIONS

LG has faster gastrointestinal recovery, better postoperative nutritional status, and comparable oncological outcomes than OG, which can serve as an alternative surgical method for LAGC patients after NC.

Risk factors for postoperative pancreatic fistula (POPF) in gastric cancer patients: A systematic review and meta-analysis

BACKGROUND

Postoperative pancreatic fistula (POPF) is a common and serious consequence of gastrectomy. The prevalence of POPF among patients with gastric cancer varies greatly, and the risk factors and outcomes of POPF are also controversial. The meta-analysis aims to comprehensively assess the risk factors for POPF in gastric cancer patients.

METHODS

PubMed, Web of Science, the Cochrane Library, Embase, and Chinese databases (SinoMed, CNKI, WanFang, and VIP Databases) were searched to identify relevant studies (from inception to May 2023). Two researchers evaluated the literature quality and extracted data individually. The Review Manager 5.4 program was used to analyze all of the data.

RESULTS

In our meta-analysis, 22 studies totaling 11,647 patients were analyzed. Male sex (OR = 3.06), older age (OR = 3.22), body mass index (BMI) ≥ 25 kg/m2 (OR = 2.58), visceral fat area (VFA) ≥ 100 cm2 (OR = 3.65), pTNM Ⅲ-Ⅳ (OR = 2.47), the number of lymphlode dissections (OR = 1.04), neoadjuvant chemotherapy (NAC) (OR = 2.91), the application of LigaSure (OR = 3.30), open surgery (OR = 3.23), intraoperative combined organ resection (OR = 4.11), drainage amylase concentration on the first postoperative day (OR = 5.73) and C-reactive protein on the 3rd postoperative day ≥20 mg/dL (OR = 7.29) were the risk factors for POPF in gastric cancer patients. On the other hand, the operation time (OR = 1.34) was not a risk factor for POPF.

CONCLUSION

The frequency of POPF in people undergoing gastrectomy was determined by a variety of risk factors. Medical professionals should identify risk factors early and impose interventions to prevent them to lower the incidence of POPF in gastric cancer patients.

Safety and efficacy of immunotherapy plus chemotherapy as neoadjuvant treatment for patients with locally advanced gastric cancer: a retrospective cohort study

BACKGROUND

The combined use of programmed death receptor-1 (PD-1) inhibitors and chemotherapy has reshaped the treatment landscape of advanced or metastatic gastric cancer (GC). This study aimed to assess the efficacy and safety of PD-1 inhibitors combined with chemotherapy in a neoadjuvant setting for locally advanced GC (LAGC).

METHODS

Patients diagnosed with clinical stage II-III GC undergoing neoadjuvant PD-1 inhibitors plus chemotherapy were enrolled from December 2019 to July 2022. Clinicopathological characteristics, pathological information, and survival data were recorded and analyzed.

RESULTS

A total of 42 eligible patients were enrolled, of whom 37 (88.1%) had clinical stage III disease. All the patients underwent surgery, and the R0 resection rate was 90.5%. Major pathological response (MPR) and pathological complete response (pCR) rates were 42.9% and 26.2%, respectively. The overall TNM downstaging rate was 76.2%. A total of 36 (85.7%) patients received adjuvant chemotherapy. With a median follow-up of 23.1 months, four patients died after tumor recurrence, and three were alive with recurrence. The 1-year overall survival (OS) and disease-free survival (DFS) rates were 94.4% and 89.5%, respectively, and the median OS and DFS were not reached. Neoadjuvant treatment was well tolerated with no grade 4-5 treatment-related adverse events (TRAEs) observed. The most common grade 3 TRAEs were anemia and alanine aminotransferase increase (n = 2 each, 9.6%).

CONCLUSIONS

PD-1 inhibitors plus chemotherapy demonstrated promising efficacy, with encouraging pCR and survival outcomes in a neoadjuvant setting for patients with LAGC. The combined therapy also showed a good safety profile.

Oncological outcomes of laparoscopic versus open radical total gastrectomy for upper-middle gastric cancer after neoadjuvant chemotherapy: a study of real-world data

BACKGROUND

Laparoscopic technique has been increasingly used in gastrectomy, but the safety and feasibility of the laparoscopic total gastrectomy (LTG) for advanced proximal gastric cancer (PGC) after neoadjuvant chemotherapy (NAC) is unclear.

METHODS

A retrospective analysis of 146 patients who received NAC followed by radical total gastrectomy at Fujian Medical University Union Hospital from January 2008 to December 2018 was performed. The primary endpoints were long-term outcomes.

RESULTS

The patients were divided into two groups: 89 were in the LTG group and 57 were in the open total gastrectomy (OTG) group. The LTG group had a significantly shorter operative time (median 173 min vs. 215 min, p < 0.001), less intraoperative bleeding (62 ml vs. 135 ml, p < 0.001), higher total lymph node (LN) dissections (36 vs 31, p = 0.043), and higher total chemotherapy cycle completion rate (≥ 8 cycles) (37.1% vs. 19.7%, p = 0.027) than OTG. The 3-year overall survival (OS) of the LTG group was significantly higher than that of the OTG group (60.7% vs. 35%, p = 0.0013). Survival with inverse probability weighting(IPW) correction for Lauren type, ypTNM stage, NAC schemes and the times at which the surgery was performed showed that there was no significant difference in OS between the two groups (p = 0.463). Postoperative complications (25.8% vs. 33.3%, p = 0.215) and recurrence-free survival (RFS) (p = 0.561) between the LTG and OTG groups were also comparable.

CONCLUSION

In experienced gastric cancer surgery centers, LTG is recommended as the preferred option for such patients who performed NAC, owing to its long-term survival is not inferior to OTG, and it offers less intraoperative bleeding, better chemotherapy tolerance than conventional open surgery.

Neoadjuvant Immunotherapy for Patients with dMMR/MSI-High Gastrointestinal Cancers: A Changing Paradigm

Immune checkpoint inhibitors have revolutionized the management of mismatch repair-deficient (MMR-D)/microsatellite instability-high (MSI-H) gastrointestinal cancers, particularly colorectal cancer. Cancers with the MMR-D/MSI-H genotype often carry a higher tumor mutation burden with frameshift alterations, leading to increased mutation-associated neoantigen (MANA) generation. The dramatic response seen with immune checkpoint inhibitors (ICIs), which are orchestrated by MANA-primed effector T cells, resulted in the rapid development of these novel therapeutics within the landscape of MSI-H gastrointestinal cancers. Recently, several clinical trials have utilized ICIs as potential neoadjuvant therapies for MSI-H gastrointestinal cancers and demonstrated deep clinical and pathological responses, creating opportunities for organ preservation. However, there are potential challenges to the neoadjuvant use of ICIs for certain disease types due to the clinical risk of overtreatment for a disease that can be cured through a surgery-only approach. In this review article, we discuss neoadjuvant management approaches with ICI therapy for patients with MSI-H gastrointestinal cancers, including those with oligometastatic disease. We also elaborate on potential challenges and opportunities for the neoadjuvant utilization of ICIs and provide further insight into the changing treatment paradigm of MMR-D/MSI-H gastrointestinal cancers.

Patients Undergoing Systemic Anti-Cancer Therapy Who Require Surgical Intervention: What Surgeons Need to Know

As part of routine cancer care, patients may undergo elective surgery with the aim of long-term cure. Some of these patients will receive systemic anti-cancer therapy (SACT) in the neoadjuvant and adjuvant settings. The majority of patients, usually with locally advanced or metastatic disease, will receive SACT with palliative intent. These treatment options are expanding beyond traditional chemotherapy to include targeted therapies, immunotherapy, hormone therapy, radionuclide therapy and gene therapy. During treatment, some patients will require surgical intervention on an urgent or emergency basis. This narrative review examined the evidence base for SACT-associated surgical risk and the precautions that a surgical team should consider in patients undergoing SACT.

Comparison of Laparoscopic and Open Gastrectomy for Patients With Gastric Cancer Treated With Neoadjuvant Chemotherapy: A Multicenter Retrospective Study Based on the Korean Gastric Cancer Association Nationwide Survey

PURPOSE

Despite scientific evidence regarding laparoscopic gastrectomy (LG) for advanced gastric cancer treatment, its application in patients receiving neoadjuvant chemotherapy remains uncertain.

MATERIALS AND METHODS

We used the 2019 Korean Gastric Cancer Association nationwide survey database to extract data from 489 patients with primary gastric cancer who received neoadjuvant chemotherapy. After propensity score matching analysis, we compared the surgical outcomes of 97 patients who underwent LG and 97 patients who underwent open gastrectomy (OG). We investigated the risk factors for postoperative complications using multivariate analysis.

RESULTS

The operative time was significantly shorter in the OG group. Patients in the LG group had significantly less blood loss than those in the OG group. Hospital stay and overall postoperative complications were similar between the two groups. The incidence of Clavien-Dindo grade ≥3 complications in the LG group was comparable with that in the OG group (1.03% vs. 4.12%, P=0.215). No statistically significant difference was observed in the number of harvested lymph nodes between the two groups (38.60 vs. 35.79, P=0.182). Multivariate analysis identified body mass index (odds ratio [OR], 1.824; 95% confidence interval [CI], 1.029-3.234; P=0.040) and extent of resection (OR, 3.154; 95% CI, 1.084-9.174; P=0.035) as independent risk factors for overall postoperative complications.

CONCLUSIONS

Using a large nationwide multicenter survey database, we demonstrated that LG and OG had comparable short-term outcomes in patients with gastric cancer who received neoadjuvant chemotherapy.

Neoadjuvant Therapy with Immune Checkpoint Inhibitors in Gastric Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

Immune checkpoint inhibitors (ICIs) have shown great promise in treating late-stage gastric cancer, but their efficacy in the neoadjuvant setting has not been studied in large cohorts. Here, we explored the efficacy and safety of neoadjuvant ICI-based therapy in locally advanced gastric cancer.

PATIENTS AND METHODS

We included studies containing patients with locally advanced gastric/gastroesophageal cancer who received ICI-based neoadjuvant therapy. We searched PubMed, Embase, Cochrane library, and abstracts from major international oncology conferences. We performed this meta-analysis using the META package in R.3.6.1.

RESULTS

Twenty-one prospective phase I/II studies comprising 687 patients were identified. The pathological complete response (pCR) rate was 0.21 (95% CI 0.18-0.24), major pathological response (MPR) rate was 0.41 (95% CI 0.31-0.52), and R0 resection rate was 0.94 (95% CI 0.92-0.96). The efficacy was highest with ICI plus radiochemotherapy, lowest with ICI alone, and in the middle with ICI and chemotherapy ± anti-angiogenesis. dMMR/MSI-H and PD-L1-high patients benefited more than pMMR/MSS and PD-L1-low patients. Grade 3 or higher toxicity rate was 0.23 (95% CI 0.13-0.38). These results exceeded those in trials of neoadjuvant chemotherapy, where the rate of pCR was 0.08 (95% CI 0.06-0.11), MPR was 0.22 (95% CI 0.19-0.26), R0 section was 0.84 (95% CI 0.80-0.87), and overall grade 3 or higher toxicity was 0.28 (95% CI 0.13-0.47) in 4800 patients across 21 studies.

CONCLUSIONS

In summary, the integrated results show promising efficacy and safety of ICI-based neoadjuvant therapy for locally advanced gastric cancer and support further investigation in large multicenter randomized trials.

Endoscopic Histoacryl injection for esophagojejunostomy leakage after total gastrectomy in patients with gastric cancer

Purpose

Esophagojejunostomy leakage after total gastrectomy for gastric cancer is one of the most serious and sometimes life-threatening adverse events. The purpose of this study was to evaluate complications after total gastrectomy in patients with gastric cancer during the period when Histoacryl (B. Braun) injection was performed. Therapeutic outcome of endoscopic Histoacryl injection for esophagojejunostomy leakage was also determined.

Methods

This was a single-center retrospective study. Between January 2016 and December 2021, clinicopathologic characteristics and surgical outcomes of 205 patients who underwent total gastrectomy were investigated. Baseline characteristics and clinical outcomes of 10 patients with esophagojejunostomy leakage were also investigated.

Results

Postoperative complication and mortality rates of total gastrectomy in 205 patients were 25.4% and 0.9%, respectively. Serious complications more than Clavien-Dindo IIIb accounted for 6.3%. Ten (4.9%) esophagojejunostomy leakages occurred in 205 patients. Among 10 esophagojejunostomy leakage patients, endoscopic Histoacryl injection was performed on eight patients and leakage was successfully managed with endoscopic Histoacryl injection in seven patients (87.5%). Mean postinjection hospital stay of seven successfully managed patients was 13.8 days. They were able to drink water at 1-6 days after injection. Among eight patients with endoscopic Histoacryl injection, six patients were injected once and two patients were injected three times.

Conclusion

Endoscopic Histoacryl injection for esophagojejunostomy leakage after total gastrectomy can be considered as a useful treatment for some selected cases.

Effects of perioperative blood transfusion in gastric cancer patients undergoing gastrectomy: A systematic review and meta-analysis

Background

The short-term and long-term effects of perioperative blood transfusion (PBT) on patients with gastric cancer are still intriguing. This systematic review and meta-analysis aimed to investigate the effects of blood transfusion on clinical outcomes in patients with gastric cancer undergoing gastrectomy.

Methods

We searched PubMed, Web of Science, Embase, and The Cochrane Library on December 31th 2021. The main outcomes were overall survival (OS), disease-free survival (DFS), disease-specific survival (DFS), and postoperative complications. A fixed or random-effects model was used to calculate the hazard ratio (HR) with 95% confidence intervals (CIs).

Results

Fifty-one studies with a total of 41,864 patients were included for this review and meta-analysis. Compared with patients who did not receive blood transfusions (NPBT), PBT was associated with worse 5-year OS (HR = 2.39 [95%CI: 2.00, 2.84]; p < 0.001; Multivariate HR = 1.43 [95%CI: 1.24, 1.63]; p < 0. 001), worse 5-year DFS (HR = 2.26 [95%CI: 1.68, 3.05]; p < 0.001; Multivariate HR = 1.45 [95%CI: 1.16, 1.82]; p < 0. 001), and worse 5-year DSS (HR = 2. 23 [95%CI: 1.35, 3.70]; p < 0.001; Multivariate HR = 1.24 [95%CI: 0.96, 1.60]; p < 0.001). Moreover, The PBT group showed a higher incidence of postoperative complications [OR = 2.30 (95%CI:1.78, 2. 97); p < 0.001] than that in the NPBT group, especially grade III-V complications, according to the Clavien-Dindo classification. [OR = 2.50 (95%CI:1.71, 3.63); p < 0.001].

Conclusion

In patients who underwent gastrectomy, PBT was associated with negative survival effects (OS, DFS, DSS) and a higher incidence of perioperative complications. However, more research was expected to further explore the impact of PBT. Meanwhile, strict blood transfusion management should be implemented to minimize the use of PBT.

Impact of perioperative chemotherapy in the treatment of patients with gastric cancer

Background

Perioperative chemotherapy (PeriCh) is the current standard of care for stage II/III gastric cancer tumors in Europe. However, when it concerns patients who endure complications during PeriCh it is unclear if it increases the risk of postoperative complications and other poorer surgical outcomes. We aim to demonstrate if there is an association between having complications during PeriCh and postoperative complications and histopathological response.

Methods

We conducted a retrospective, transversal, and observational study, including all patients with diagnosed gastric cancer who underwent PeriCh followed by surgical resection during the period of eight years.

Results

We included 80 patients with a median age of 64.0years (min 24, max 78). Eighty-eight-point eight percent ended the chemotherapy regime proposed, with a median duration of 42 days, and were also submitted to gastric resection: 58.8% total gastrectomy and 41.2% distal gastrectomy. Twelve-point five percent of the patients had no complications during the PeriCh period and 16.3% had >2 complications. Twenty-five percent of patients had a histological response of <10% of tumor burden, but in 41.3% only regression of <50% could be obtained. No significant association was found between complications during PeriCh and adverse surgical outcomes (P = .497). Patients with complications during PeriCh had slightly higher median time difference from end of PeriCh until surgery, but with no statistical significance (P = .575).

Conclusions

In our sample, the existence of association between complications during PeriCh and postoperative complications or histological response was not demonstrated.

The safety and efficacy of laparoscopic gastrectomy for patients with locally advanced gastric cancer following neoadjuvant chemotherapy

Limited researches focused on the application of laparoscopic gastrectomy (LG) in locally advanced gastric cancer (LAGC) patients following neoadjuvant chemotherapy (NACT). In this study, we aimed at illustrating the surgical and survival outcome of LG in LAGC patients following NACT. We performed a retrospective study of patients with LAGC who received either LG following NACT or upfront LG at Fujian Provincial Hospital between March 2013 and October 2018. Perioperative parameters, short-term and long-term outcomes were compared. The Kaplan–Meier estimator was used to describe the survival curves, and the differences were examined by the log-rank test. In total, 76 consecutive patients were enrolled into the NACT-LG (41 patients) and LG (35 patients) group. The postoperative hospital stay was significantly longer for LG than for NACT-LG (11.0 vs. 12.0 day, P = 0.031). Significant difference was found in Grade ≥ III severe postoperative complications in two groups (0 vs. 17.1%, P = 0.001). No patient died of postoperative complications in the NACT-LG group, and one patient (1/35, 2.9%) died of postoperative complications in the LG group. A forest plot revealed that most subgroups of LG group were at great risks of postoperative complications. Compared with the LG group, the NACT-LG group had a significantly better DFS (14.4% vs. 5.7%, P = 0.0299) and better OS (34.1% vs. 8.6%, P = 0.0061) at 3 years. NACT increased the safety of LG for patients with LAGC and offer better disease-free and overall survival. For patients with LAGC, LG following NACT should be the priority treatment.

Early and late recurrences in lymph node-negative gastric cancer: a retrospective cohort study

BACKGROUND

Predictors of recurrence in patients with lymph node-negative gastric cancer (GC) who have undergone curative resection have been widely investigated, but not the effects of predictors on timing of recurrence.

OBJECTIVE

Determine the factors associated with early and late recurrence in patients with node-negative GC.

DESIGN

Retrospective cohort.

SETTING

Academic tertiary care center.

PATIENTS AND METHODS

The study included patients with node-negative GC after curative resection between 2008 and 2018 at two institutions. Early and late recurrences were determined using a minimum P value approach to evaluate the optimal cutoff for recurrence-free survival (RFS). A competing risk model and landmark analysis were used to analyze factors associated with early and late recurrences.

MAIN OUTCOME MEASURES

Recurrence-free survival and factors associated with survival.

SAMPLE SIZE

606.

RESULTS

After a median follow-up of 70 months, 50 (8.3%) patients experienced recurrent disease. The optimal length of RFS for distinguishing between early (n=26) and late recurrence (n=24) was 24 months (P=.0013). The median RFS in the early and late recurrence groups was 11 and 32 months, respectively. Diffuse tumors (hazard ratio 3.358, P=.014), advanced T stage (HR 8.804, P=.003), perineural invasion (HR 10.955, P<.001), and anemia (HR 2.351, P=.018) were independent predictors of early recurrence. Mixed tumor location (HR 5.586, P=.002), advanced T stage (HR 5.066, P<.001), lymphovascular invasion (HR 5.902, P<.001), and elevated CA19-9 levels (HR 5.227, P<.001) were independent predictors of late recurrence. Similar results were obtained in the landmark analysis.

CONCLUSIONS

Individualized therapeutic and follow-up strategies should be considered in future studies because of distinct patterns in predictors of early and late recurrence.

LIMITATIONS

Retrospective design, small sample size.

CONFLICT OF INTEREST

None.

Assessment of indocyanine green tracer-guided lymphadenectomy in laparoscopic gastrectomy after neoadjuvant chemotherapy for locally advanced gastric cancer: results from a multicenter analysis based on propensity matching

BACKGROUND

This study evaluated the safety, effectiveness, and feasibility of indocyanine green (ICG) tracing in guiding lymph-node (LN) dissection during laparoscopic D2 radical gastrectomy in patients with advanced gastric cancer (AGC) after neoadjuvant chemotherapy (NAC).

METHOD

We retrospectively analyzed data on 313 patients with clinical stage of cT1-4N0-3M0 who underwent laparoscopic radical gastrectomy after NAC between February 2010 and October 2020 from two hospitals in China. Grouped according to whether ICG was injected. For the ICG group (n = 102) and non-ICG group (n = 211), 1:1 propensity matching analysis was used.

RESULTS

After matching, there was no significant difference in the general clinical pathological data between the two groups (ICG vs. non-ICG: 94 vs. 94). The average number of total LN dissections was significantly higher in the ICG group and lower LN non-compliance rate than in the non-ICG group. Subgroup analysis showed that among patients with LN and tumor did not shrink after NAC, the number of LN dissections was significantly more and LN non-compliance rate was lower in the ICG group than in the non-ICG group. Intraoperative blood loss was significantly lesser in the ICG group than in the non-ICG group, while the recovery and complications of the two groups were similar.

CONCLUSION

For patients with poor NAC outcomes, ICG tracing can increase the number of LN dissections during laparoscopic radical gastrectomy, reduce the rate of LN non-compliance, and reduce intraoperative bleeding. Patients with AGC should routinely undergo ICG-guided laparoscopic radical gastrectomy.

Short-Term Clinical Efficacy of Neoadjuvant Chemotherapy Combined With Laparoscopic Gastrectomy for Locally Advanced Siewert Type II and III Adenocarcinoma of the Esophagogastric Junction: A Retrospective, Propensity Score-Matched Study

Background

Laparoscopic gastrectomy (LG) has been increasingly used for the treatment of locally advanced Siewert type II and III adenocarcinoma of the esophagogastric junction (AEG). However, whether LG can achieve the same short-term efficacy in the treatment of patients who receive neoadjuvant chemotherapy (NACT) remains controversial. Thus, the aim of this study was to investigate the clinical outcomes of NACT combined with LG for Siewert type II and III AEG.

Methods

This retrospective study identified patients with locally advanced Siewert type II and III AEG diagnosed between May 2011 and October 2020 using the clinical tumor-node-metastasis (cTNM) staging system. The short-term outcomes were compared between the matched groups using a 1:3 propensity score matching (PSM) method, which was performed to reduce bias in patient selection.

Results

After PSM, 164 patients were selected, including 41 in the NACT group and 123 in the LG group. The baseline characteristics were similar between the two groups. Compared with the LG group, the NACT group exhibit a smaller tumor size and significantly less advanced pathological tumor classification and nodal classification stages. The time to first flatus of the NACT group was significantly shorter, but the hospital stay was significantly longer than that of the LG group. The NACT group showed similar overall (29.3% vs 25.2%, P=0.683), systemic (24.4% vs 21.1%, P=0.663), local (12.2% vs 9.8%, P=0.767), minor (19.5% vs 19.5%, P=1.000) and major (9.8% vs 5.7%, P=0.470) complications as the LG group. Subgroup analyses showed no significant differences in most stratified parameters. Operation time≥ 300 minutes was identified as an independent risk factor for overall complications. Age≥ 60 years was identified as an independent risk factor for major complications.

Conclusion

NACT combined with LG for AEG does not increase the risk of postoperative morbidity and mortality compared with LG.

Long-Term Outcomes of Laparoscopic Radical Gastrectomy for Highly Advanced Gastric Cancer: Final Report of a Prospective Phase II Trial (KUGC04)

BACKGROUND

This is the final report evaluating the long-term outcomes of a single-arm phase II clinical trial that demonstrated the short-term efficacy of laparoscopic gastrectomy (LG) for highly advanced gastric cancer (AGC) [KUGC04].

PATIENTS AND METHODS

Seventy-three patients with histologically confirmed gastric adenocarcinoma and diagnosed with clinical stage II or higher, who potentially underwent curative resection between August 2009 and November 2014, were prospectively enrolled. Long-term outcomes with 5-year progression-free survival (PFS) and 5-year overall survival (OS) were evaluated according to clinical or pathological stages. Recurrence and progression patterns were also investigated. These outcomes were compared with those of previous reports to assess the applicability of LG for highly advanced gastric cancer (HAGC).

RESULTS

The median observation period of all surviving patients was 75.1 months. The 5-year PFS and 5-year OS of all patients was 47.4% and 54.4%, respectively. Clinical stage-specific 5-year PFS and 5-year OS was 75.0, 69.1, 53.9, 39.4, 40.0 and 9.1, and 75.0, 68.8, 61.5, 45.0, 60.0 and 27.3, respectively, in stages IIA, IIB, IIIA, IIIB, IIIC, and IV, respectively. Pathological stage-specific 5-year PFS and 5-year OS, including ypStage with preoperative chemotherapy, was 100, 80.0, 100, 62.5, 80.0, 51.3, 16.7, 22.2 and 12.5, and 100, 80.0, 100, 75.0, 80.0, 64.2, 25.0, 33.3 and 12.5, respectively, in stage X (no residual tumor with preoperative chemotherapy), IA, IB, IIA, IIB, IIIA, IIIB, IIIC, and IV, respectively. Recurrence or progression was observed in 30 patients (41.1%).

CONCLUSION

LG for HAGC performed by experienced surgeons is safe and oncologically acceptable.

Clinical Impact of a Perioperative Exercise Program for Sarcopenia and Overweight/Obesity Gastric Cancer

Gastrectomy with D2 lymph node dissection and perioperative adjuvant treatment is the standard treatment for locally advanced gastric cancer. However, the morality rate is reported to be 20%-40% after gastrectomy for gastric cancer. Perioperative sarcopenia and obesity are strongly related to postoperative surgical complications after gastrectomy. Furthermore, recent studies have shown that postoperative surgical complications are related to long-term oncological outcomes. If we can prevent or improve perioperative sarcopenia or obesity in gastric cancer patients, the rate of postoperative surgical complications in these patients might be reduced, thereby improving the long-term oncological outcomes. Given this hypothesis, recent studies have focused on enacting perioperative exercise programs for gastric cancer patients with sarcopenia and overweight/obesity. Such exercise programs have proven promising and demonstrated some clinical benefits for gastric cancer patients with sarcopenia and overweight/obesity. However, whether or not perioperative exercise programs have clinical benefits with regard to long-term oncological outcomes in gastric cancer patients is unclear. To optimize these perioperative exercise programs for gastric cancer patients, it is necessary to clarify the benefits with regard to the long-term oncological outcomes in these patients and establish an optimal perioperative exercise program.

Could neoadjuvant chemotherapy increase postoperative complication risk of laparoscopic total gastrectomy? A mono-institutional propensity score-matched study in China

BACKGROUND

The potential survival benefit of neoadjuvant chemotherapy (NC) in patients with advanced gastric cancer has been widely recognized. With the development of minimally invasive surgery, which is represented by laparoscopy, the effect of NC on the safety of laparoscopic gastrectomy remains to be further explored.

AIM

To compare the short-term outcomes of laparoscopic total gastrectomy (LTG) after NC (NC-LTG) with LTG alone.

METHODS

A total of 92 patients who underwent NC-LTG and 381 patients who received LTG alone at the Chinese PLA General Hospital between September 2015 and September 2020 were retrospectively included in our study. We used propensity-score matching (PSM) to balance baseline bias. After 1:1 PSM, 73 patients were included in each group with no statistically significant difference in baseline characteristics.

RESULTS

The NC-LTG group exhibited a longer operation time (244.10 ± 48.13 min vs 225.74 ± 45.33 min, P = 0.019) and increased intraoperative blood loss [150 (100-300) mL vs 100 (100-200) mL, P = 0.011] compared to the LTG group. The 30-d postoperative morbidity of the NC-LTG group was 20.5% (15/73), and that of the LTG group was 13.7% (10/73). There were no significant differences in 30-d severe complication rates or anastomotic leakage rates. Subgroup analysis showed that the patients with pTNM (pathological tumor-node-metastasis classification) T0N0-II in the NC-LTG group underwent a longer operation than the LTG group, while no significant difference was found in any perioperative index for the pTNM III patients. A multivariate analysis showed that an operation time longer than 240 min was an independent risk factor (odds ratio = 3.021, 95% confidence interval: 1.160-7.868, P = 0.024), while NC was not an independent risk factor for postoperative complications in LTG.

CONCLUSION

Despite a longer operation time and more blood loss after NC-LTG, which indicate surgical difficulty, NC-LTG exhibits acceptable short-term outcomes compared to LTG, suggesting the safety and feasibility of NC-LTG.

Assessment of Robotic Versus Laparoscopic Distal Gastrectomy for Gastric Cancer: A Randomized Controlled Trial

OBJECTIVE

To evaluate the short-term outcomes of patients with GC who received RDG or LDG.

SUMMARY BACKGROUND DATA

Despite the increasing use of RDG in patients with GC, its safety and efficacy compared to those of LDG have not been elucidated in a randomized controlled trial.

METHODS

Three hundred patients with cT1-4a and N0/+ between September 2017 and January 2020 were enrolled in this randomized controlled trial at a high-volume hospital in China. The short-term outcomes were compared between the groups.

RESULTS

The modified intention-to-treat analysis included data from 283 patients (RDG group: n = 141) and (LDG group: n = 142). Patients in the RDG group exhibited faster postoperative recovery, milder inflammatory responses, and reduced postoperative morbidity (9.2% vs 17.6%, respectively, P = 0.039). Higher extraperigastric lymph nodes (LNs) were retrieved in the RDG group (17.6 ± 5.8 vs 15.8 ± 6.6, P = 0.018) with lower noncompliance rate (7.7% vs 16.9%, respectively, P = 0.006). Additionally, patients in the RDG group were more likely to initiate adjuvant chemotherapy earlier [median (interquartile range) postoperative days: 28 (24-32) vs 32 (26-42), P = 0.003]. Although total hospital costs were higher in the robotic group than in the laparoscopic group, the direct cost was lower for RDG than for LDG (all P < 0.001).

CONCLUSIONS

RDG is associated with a lower morbidity rate, faster recovery, milder inflammatory responses, and improved lymphadenectomy. Additionally, faster postoperative recovery in the RDG group enables early initiation of adjuvant chemotherapy. Our results provide evidence for the application of RDG in patients with GC.

Adverse Prognostic Impact of Postoperative Complications After Gastrectomy for Patients With Stage II/III Gastric Cancer: Analysis of Prospectively Collected Real-World Data

BACKGROUND

The impact of postoperative complications on the prognosis of gastric cancer remains controversial. This study aimed to evaluate the relationship between postoperative complications and long-term survival in patients undergoing gastrectomy for stage II/III gastric cancer.

METHODS

Some 939 patients underwent curative gastrectomy for stage II/III gastric cancer were identified from real-world data prospectively collected between 2013 and 2015. We divided patients according to the presence of serious complications, specifically, Clavien-Dindo grade III or higher complications or those causing a hospital stay of 15 days or longer.

RESULTS

Serious complications occurred in 125 (13.3%) patients. Patients without serious complications (64.3%) completed adjuvant chemotherapy significantly more than patients with serious complications (37.6%; p<0.001). The 5-year overall survival(OS) rate was 58.1% and recurrence-free survival(RFS) rate was 58.1% in patients with serious complications, which were significantly worse than those of patients without serious complications (73.4% and 74.7%, respectively; p<0.001 for both). In stage II, once patients completed adjuvant chemotherapy adequately, the OS and RFS of patients with serious complications did not differ from those without serious complications. However, in stage III, the patients with serious complications showed a worse OS even after completion of adequate adjuvant chemotherapy.

CONCLUSION

Serious complications after gastrectomy had a negative impact on the prognosis of stage II/III gastric cancer patients. Serious complications worsen the survival in association with inadequate adjuvant chemotherapy. Efforts to reduce serious complications, as well as support adequate chemotherapy through proper management of serious complications, would improve the prognosis of stage II/III gastric cancer patients.

Long-term oncologic outcomes of robotic versus laparoscopic gastrectomy for locally advanced gastric cancer: a propensity score-matched analysis of 1170 patients

BACKGROUND

The robotic surgical system has several technical advantages over laparoscopic instruments. The technical feasibility and safety of robotic gastrectomy (RG) for gastric cancer have been reported by increasing number of studies. However, the long-term survival and recurrence outcomes after RG for locally advanced gastric cancer (AGC) have seldom been reported. This study aimed to compare long-term oncologic outcomes for patients with locally AGC after RG or laparoscopic gastrectomy (LG).

METHODS

This study comprised 1170 patients underwent RG or LG, respectively, for locally AGC between March 2010 and February 2017. The primary outcome was the 3-year disease-free survival (DFS). The secondary endpoint included 3-year overall survival (OS) and recurrence patterns. One-to-one propensity score matching (PSM) was performed to reduce confounding bias. The outcomes were compared in PSM cohort.

RESULTS

After PSM, a well-balanced cohort of 816 patients (408 in each group) were included in the analysis. The 3-year DFS rate was 76.2% in the robotic group and 70.1% in the laparoscopic group (P = 0.076). The 3-year OS rates was 76.7% in the robotic group and 73.3% in the laparoscopic group (P = 0.246). In the subgroup analyses for potential confounding variables, neither 3-year DFS nor 3-year OS survival were significantly different between the two groups (all P > 0.05). The two groups showed similar recurrence patterns within 3 years after surgery (P > 0.05).

CONCLUSION

For patients with locally AGC, RG can result in comparable long-term survival outcomes without an increase in recurrence rate.

The Predictive Value of Low Muscle Mass as Measured on CT Scans for Postoperative Complications and Mortality in Gastric Cancer Patients: A Systematic Review and Meta-Analysis

Risk assessment is relevant to predict outcomes in patients with gastric cancer. This systematic review aimed to investigate the predictive value of low muscle mass for postoperative complications in gastric cancer patients. A systematic literature search was performed to identify all articles reporting on muscle mass as measured on computed tomography (CT) scans in patients with gastric cancer. After full text screening, 15 articles reporting on 4887 patients were included. Meta-analysis demonstrated that patients with low muscle mass had significantly higher odds of postoperative complications (odds ratio (OR): 2.09, 95% confidence interval (CI): 1.55–2.83) and severe postoperative complications (Clavien–Dindo grade ≥III, OR: 1.73, 95% CI: 1.14–2.63). Moreover, patients with low muscle mass had a significantly higher overall mortality (hazard ratio (HR): 1.81, 95% CI: 1.52–2.14) and disease-specific mortality (HR: 1.58, 95% CI: 1.36–1.84). In conclusion, assessment of muscle mass on CT scans is a potential relevant clinical tool for risk prediction in gastric cancer patients. Considering the heterogeneity in definitions applied for low muscle mass on CT scans in the included studies, a universal cutoff value of CT-based low muscle mass is required for more reliable conclusions.

The optimal timing of additional surgery after non-curative endoscopic resection to treat early gastric cancer: long-term follow-up study

Patients with early gastric cancer (EGC) who undergo non-curative endoscopic resection (ER) require additional surgery. The aim of the study was to validate surgical and oncological outcomes according to the timing of additional surgery after non-curative endoscopic resection. We retrospectively analyzed long-term follow-up data on the 302 patients enrolled between January 2007 and December 2014. We validated our earlier suggestion that the optimal time interval from non-curative ER to additional surgery was 29 days. All patients were divided into two groups by reference to time intervals from ER to additional surgery of ≤29days (n = 133; group A) and >29 days (n = 169; group B). The median follow-up duration was 41.98 ± 21.23 months. As in our previous study, group B exhibited better surgical outcomes. A total of 10 patients developed locoregional or distant recurrences during the follow-up period, but no significant difference was evident between the two groups. Interestingly, the survival rate was better in group B. Group B (>29 days) exhibited better surgical and oncological outcomes. Thus, additional gastrectomy after non-curative ER should be delayed for 1 month to ensure optimal surgical and oncological outcomes.

Assessment of Laparoscopic Distal Gastrectomy After Neoadjuvant Chemotherapy for Locally Advanced Gastric Cancer: A Randomized Clinical Trial

Importance

Laparoscopic distal gastrectomy and neoadjuvant chemotherapy are increasingly used to treat locally advanced gastric cancer. However, the safety and efficacy of the laparoscopic procedure after neoadjuvant chemotherapy remain unclear.

Objective

To evaluate the short-term outcomes of patients with locally advanced gastric cancer who received either laparoscopic distal gastrectomy or open distal gastrectomy.

Design, Setting, and Participants

Between April 23, 2015, and November 16, 2017, a phase 2, open-label, noninferiority randomized clinical trial was conducted at the Gastrointestinal Cancer Center of Peking University Cancer Hospital and Institute in Beijing, China. Patients (n = 96) between 18 and 80 years of age with locally advanced gastric cancer (cT2-4aN+M0) who were receiving neoadjuvant chemotherapy were enrolled and randomized. An as-treated population and a modified intention-to-treat (mITT) population were defined for the data analysis.

Interventions

Patients were randomized to undergo either laparoscopy-assisted distal gastrectomy (LADG) with D2 lymphadenectomy or open distal gastrectomy (ODG) with D2 lymphadenectomy.

Main Outcomes and Measures

The primary end point was 3-year recurrence-free survival rate. Secondary end points were surgical radicality, 30-day postoperative morbidity and mortality, 2-week postoperative recovery indexes, and adjuvant chemotherapy completion status.

Results

In total, 95 patients were eligible for as-treated analyses (LADG: 45, of whom 13 were female [29%], with a median [interquartile range (IQR)] age of 59 [52-65] years; ODG: 50, of whom 16 were female [32%], with a median [IQR] age of 61 [55-64] years) and mITT analyses (LADG: 47, of whom 14 were female [30%], with a median [IQR] age of 59 [52-65] years; ODG: 48, of whom 15 were female [31%], with a median [IQR] age of 61 [55-64] years). In the as-treated analyses, the LADG group had a significantly lower postoperative complication rate than the ODG group (20% vs 46%; P = .007). The postoperative visual analog scale score for pain was 1.2 units lower on postoperative day 2 only in the LADG group (95% CI, -2.1 to -0.3; P = .008). Patients in the LADG group had better adjuvant chemotherapy completion (adjusted odds ratio, 4.39; 95% CI, 1.63-11.80; P = .003) and were less likely to terminate adjuvant chemotherapy because of adverse effects (10 [22%] vs 21 [42%]; P = .04). The mITT analyses showed similar results to as-treated analyses.

Conclusions and Relevance

This trial found that LADG appears to offer the benefits of better postoperative safety and adjuvant chemotherapy tolerance compared with ODG for patients with locally advanced gastric cancer who received neoadjuvant chemotherapy.

Trial Registration

ClinicalTrials.gov identifier: NCT02404753.

Deep Learning-Based Survival Analysis Identified Associations Between Molecular Subtype and Optimal Adjuvant Treatment of Patients With Gastric Cancer

Purpose

Gastric cancer (GC) is the third-leading cause of cancer-related deaths. Several pivotal clinical trials of adjuvant treatments were performed during the previous decade; however, the optimal regimen for adjuvant treatment of GC remains controversial.

Patients and Methods

We developed a novel deep learning–based survival model (survival recurrent network [SRN]) in patients with GC by including all available clinical and pathologic data and treatment regimens. This model uses time-sequential data only in the training step, and upon being trained, it receives the initial data from the first visit and then sequentially predicts the outcome at each time point until it reaches 5 years. In total, 1,190 patients from three cohorts (the Asian Cancer Research Group cohort, n = 300; the fluorouracil, leucovorin, and radiotherapy cohort, n = 432; and the Adjuvant Chemoradiation Therapy in Stomach Cancer cohort, n = 458) were included in the analysis. In addition, we added Asian Cancer Research Group molecular classifications into the prediction model. SRN simulated the sequential learning process of clinicians in the outpatient clinic using a recurrent neural network and time-sequential outcome data.

Results

The mean area under the receiver operating characteristics curve was 0.92 ± 0.049 at the fifth year. The SRN demonstrated that GC with a mesenchymal subtype should elicit a more risk-adapted postoperative treatment strategy as a result of its high recurrence rate. In addition, the SRN found that GCs with microsatellite instability and GCs of the papillary type exhibited significantly more favorable survival outcomes after capecitabine plus cisplatin chemotherapy alone.

Conclusion

Our SRN predicted survival at a high rate, reaching 92% at postoperative year 5. Our findings suggest that SRN-based clinical trials or risk-adapted adjuvant trials could be considered for patients with GC to investigate more individualized adjuvant treatments after curative gastrectomy.

MicroRNA-744 promotes cell apoptosis via targeting B cell lymphoma-2 in gastric cancer cell line SGC-7901

Gastric cancer (GC) affects the health of 1,000,000 people per year worldwide; however, the biological basis of GC remains largely unknown. The current study aimed to investigate the aberrant expression of miR-744 in GC for the effective treatment of patients with GC. Tumor and adjacent tissues were obtained from 30 patients who underwent tumor resection surgery at Dongying People's Hospital. The results of reverse transcription-quantitative polymerase chain reaction indicated that the expression of miR-744 was significantly decreased in tumor tissues compared with the levels in adjacent tissues. Human gastric cancer cell line SGC-7901 was then randomly divided into three different groups, including the control, miR-negative control (NC) and miR-744 mimic groups. A Cell Counting Kit-8 assay demonstrated that there was a significant decrease in the proliferation rate of SGC-7901 cells in the miR-744 mimics group compared with that observed in the control and miR-NC mimics groups. In addition, flow cytometry demonstrated that apoptosis was significantly increased in the miR-744 mimics group compared with that observed in the control and miR-NC mimics groups. Western blotting indicated that the expression of B cell lymphoma 2 (Bcl-2), B cell lymphoma-2-associated X protein and caspase-3 protein was significantly increased, while the expression of Bcl-2 was significantly decreased in the miR-744 mimics group compared with the levels observed in the control and miR-NC mimics groups. A dual-luciferase assay verified that miR-744 directly targeted the 3'-untranslated region of Bcl-2. Taken together, the present study suggested that miR-744 serves a tumor suppressive role in GC by targeting Bcl-2.

Laparoscopic or open distal gastrectomy after neoadjuvant chemotherapy for advanced gastric cancer: study protocol for a randomised phase II trial

INTRODUCTION

Current guidelines recommend open gastrectomy with D2 lymph node dissection and adjuvant chemotherapy as the standard treatment for advanced gastric cancer. However, the prognosis is not satisfactory. Perioperative chemotherapy has been proposed to improve survival. Although still in debate, the efficacy of laparoscopic distal gastrectomy (LDG) in patients with advanced gastric cancer has been demonstrated in a few trials. Therefore, LDG after neoadjuvant chemotherapy can be a candidate for future standard treatment on advanced distal gastric cancer. We propose a randomised phase II trial to compare LDG and open distal gastrectomy (ODG) after neoadjuvant chemotherapy for advanced gastric cancer.

METHODS AND ANALYSIS

To test the efficacy and safety, a randomised, open-label, single-centre, phase II trial was designed to evaluate the non-inferiority of LDG compared with ODG after neoadjuvant chemotherapy, with 3-year recurrence-free survival as the primary endpoint. The chosen critical value of a non-inferiority margin was an increase of <8%. The study started in 2015 and enrolled 96 patients according to a prior sample size calculation. Intention-to-treat and per-protocol approach will be used for efficacy analysis, and as-treated analysis will be applied for safety analysis. The survival curves will be constructed as time-to-event plots using the Kaplan-Meier method and compared using log-rank tests and Cox proportional hazards model. All statistical analyses will be conducted in standard statistical software with a significance level of 0.05.

ETHICS AND DISSEMINATION

This study was approved by the Peking University Cancer Hospital Ethics Committee. The results will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT02404753; Pre-results.

The prognostic role of perioperative allogeneic blood transfusions in gastric cancer patients undergoing curative resection: A systematic review and meta-analysis of non-randomized, adjusted studies

The impact of allogeneic perioperative blood transfusions (APTs) on the prognosis of gastric cancer patients undergoing curative-intent gastrectomy is still a highly debated topic. Two meta-analyses were published in 2015, and new studies report conflicting results. A literature review was conducted using PubMed, Scopus, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews, updated to March 1, 2016. Thirty-eight non-randomized studies reporting data on overall survival (OS), disease-free survival (DFS), disease-specific survival (DSS) and postoperative complications (PCs) were included. An inverse variance random-effects meta-analysis was conducted. APTs showed an association with worse OS, DFS, DSS and an increased number of PCs. The hazard ratio (HR) for OS was 1.49, with a 95% confidence interval (95% CI) of 1.32-1.69 (p < .00001; Q-test p = .001, I-squared = 56%). After outlier exclusion, the HR for OS was 1.34 (95% CI = 1.23-1.45, p < .00001; Q-test p = .64, I-squared = 0%). The HR for DFS was 1.48 (95% CI = 1.18-1.86, p = .0007; Q-test p = .31, I-squared = 16%), and the HR for DSS was 1.66 (95% CI = 1.5-2.19, p = .0004; Q-test p = .96, I-squared = 0%). The odds ratio for PCs was 3.33 (95% CI = 2.10-5.29, p < .00001; Q-test p = .14, I-squared = 42%). This meta-analysis showed a significant association between transfusions and OS, DFS, DSS and PCs. The quality of the evidence was low. Aggregation, selection and selective reporting bias were detected. The biases shifted the results towards significance. Further studies using accurate adjustment methods are needed. Until such additional studies are performed, caution in administering transfusions and optimization of cancer patient blood management are warranted.

Feasibility of a Clinical Pathway With Early Oral Intake and Discharge for Laparoscopic Gastrectomy

BACKGROUND AND AIMS

Although some studies have reported the safety of early oral intake after gastrectomy, it still remains controversial. This study focused on the feasibility of a clinical pathway with early oral intake and discharge setting for exclusively laparoscopic distal gastrectomy.

MATERIALS AND METHODS

A clinical pathway was applied to 403 patients until December 2014. In the protocol, patients are allowed to take a sip of water and a soft diet on the first and second days after the operation, respectively, and the discharge day is set as the fifth to seventh day after the operation. Clinicopathological variables were prospectively collected, and risk factors for discharge variances were analyzed.

RESULTS

The completion rate of the clinical pathway was 76.9%. There were five re-admissions (1.2%). The overall morbidity rate was 18% ( n = 72), and major complications (Clavien-Dindo IIIa or greater) occurred in 13 patients (3%). Complications were the causes for discharge variances in 68 cases (73%), while the attending surgeons' judgment was the cause in 25 cases (27%). On multivariate analysis, age (odds ratio = 2.23, 95% confidence interval = 1.38-3.60, p = 0.001) and operative time (odds ratio = 2.38, 95% confidence interval = 1.45-3.98, p = 0.001) were independent risk factors for discharge variances.

CONCLUSION

A high completion rate of a clinical pathway with early oral intake and discharge setting for laparoscopic distal gastrectomy was achievable with an acceptably low re-admission rate. Laparoscopic distal gastrectomy is recommended as a first step for a clinical pathway with an early oral intake and discharge protocol.

Esophagojejunal anastomosis leakage after total gastrectomy for esophagogastric junction adenocarcinoma: options of treatment

BACKGROUND

Esophagojejunal anastomosis leakage after total gastrectomy (TG) for esophagogastric junction (EGJ) adenocarcinoma (ADC) constitutes one of the most serious and sometimes life-threatening complications. Management remains controversial and still challenging.

METHODS

A total of 198 patients operated for type I and II EGJ ADC were reviewed. Diagnosis of leakage was based on a combination of clinical and radiological findings. It was classified including objective endoscopic and clinical parameters requiring different type of treatment.

RESULTS

Anastomotic leakage was diagnosed in 14 patients (7%). Two cases recovered with conservative therapy. Six cases underwent endoscopy with clips placement in 2 and partially covered self-expandable metal stent placement in 4. Other two cases underwent reoperation with reconstruction of anastomosis and primary repair respectively. In the last four cases emergency surgery with total esophagectomy and diversion was required. Mortality occurred only in 3 of these patients and overall treatment was successful in 11 patients (78.5%).

CONCLUSIONS

No consensus has been reached on the best method of esophagojejunal anastomosis leakage management and the rate of failure remains significant. Different options of treatment are available but early detection and multidisciplinary approaches are the keys to obtain successful results irrespective of the employed strategy.

Feasibility of Laparoscopic Radical Gastrectomy for Gastric Cancer of Clinical Stage II or Higher: Early Outcomes in a Phase II Study (KUGC04)

PURPOSE

A phase II study was performed to evaluate the safety and efficacy of laparoscopic gastrectomy (LG) for gastric cancer of clinical stage II or higher.

METHODS

The eligibility criteria were gastric cancer of clinical stage II or higher that was amenable to potentially curative resection. Patients with prior chemotherapy, tumors requiring total gastrectomy (TG), tumors that invaded adjacent organs, and patients with bulky lymph node metastasis were included. The primary endpoint was incidence of postoperative complications of grade II or higher in the Clavien-Dindo classification. The sample size was determined to be 73, based on an expected rate of complications of 19 % and a threshold of 30 %. Gastrectomy was performed by expert surgeons who were certified by the Japan Society for Endoscopic Surgery.

RESULTS

A total of 73 patients were enrolled; 54 patients (74 %) had clinical T stage T4a/T4b, and 47 patients (64 %) were administered preoperative chemotherapy. The type of surgery was distal gastrectomy in 41 patients and TG in 31 patients. Dissection of D2 or more was performed in 62 patients (85 %). Of the 25 patients who underwent D2/D2+ TG, 15 underwent splenectomy or pancreaticosplenectomy. R0 resection was performed in 64 patients (88 %). The median number of resected lymph nodes was 56, and postoperative complications occurred in 15 patients (20.5 %), which was significantly lower than the threshold value (p = 0.039). One in-hospital death occurred (1.4 %).

CONCLUSION

LG for gastric cancer of clinical stage II or higher can be safely performed by experienced surgeons.

A phase II study of a modified FOLFOX6 regimen as neoadjuvant chemotherapy for locally advanced gastric cancer

Background:

We evaluated the efficacy and safety of the modified FOLFOX6 (mFOLFOX6) regimen as a neoadjuvant chemotherapy in gastric cancer patients.

Methods:

Seventy-three patients with T2–T4 or N+ were enroled. Preoperative chemotherapy consisted of three cycles of mFOLFOX6. The primary end points were the response rate and the R0 resection rate. Prognostic factors for overall survival (OS) were investigated using univariate and multivariate analyses.

Results:

Sixty-seven (91.8%) patients completed 3 cycles, with grade 3–4 toxicity arising in 33.0%. The radiology response rate was 45.8%. Sixty-seven (91.8%) patients receiving radical surgery showed different levels of histological regression of the primary tumour, with a ⩾50% regression rate of 49.2%. ypTNM stage (HR 4.045, 95% CI 1.429–11.446) and tumours of diffuse and mixed type (HR 9.963, 95% CI 1.937–51.235; HR 8.890, 95% CI 1.157–68.323, respectively) were significantly associated with OS. The pathologic regression rate (GHR; ⩾2/3/<2/3, ⩾50%/<50%) was statistically significantly associated with OS according to a univariate analysis.

Conclusions:

Perioperative mFOLFOX6 was a tolerable and effective regimen for gastric cancer. The ypTNM stage was an independent predictor of survival. GHR ⩾50%/<50% could be used as a surrogate marker for selecting a postoperative chemotherapy regimen.

Correlation analyses between pre- and post-operative adverse events in gastric cancer patients receiving preoperative treatment and gastrectomy

Backgrounds

Preoperative chemotherapy (PCT) and chemoradiotherapy (PCRT) showed promising results for gastric cancers. However, the influence of preoperative adverse events (AEs) on postoperative complications remains unknown. The aim of this study was to identify correlations between them.

Methods

Clinical data and laboratory findings were retrieved retrospectively for 115 patients who underwent gastrectomy after PCT or PCRT between 2010 and 2013. Preoperative AEs and postoperative complications were classified according to the Common Terminology Criteria for Adverse Events (CTCAE) and Clavien-Dindo (CD) grading systems, respectively. Correlations between CTCAE grades and CD grades were analyzed, and clinical data and laboratory findings were compared among three groups classified according to CD grades: CD0, CD1/2, and CD3/4.

Results

There were 61 (53.0 %) patients in the CD0 group, 44 (38.3 %) patients in the CD1/2 group, and 10 (8.7 %) patients in the CD3/4 group. The CTCAE grades did not correlate with the CD grades. Only estimated blood loss (P = 0.019) and transfusion rate (P < 0.001) differed among the three CD groups.

Conclusion

There are no correlations between pre- and post-operative adverse events in the terms of severity grades in patients with advanced or metastatic gastric cancer who underwent gastrectomy after PCT or PCRT. Meticulous intraoperative manipulations should be emphasized.

DBD-F induces apoptosis in gastric cancer-derived cells through suppressing HIF2α expression

PURPOSE

Gastric cancer is the third leading cause of cancer-related death in China. Accumulating evidence indicates that HIF2α may affect the aggressiveness of gastric cancer. It has also been found that HIF2α C-terminal PAS domains can form complexes with inactive benzoxadiazole antagonists. Here, the anti-tumor effect of 4-(N,Ndimethylaminosulphonyl)-7-fluoro-1,2,3-benzoxadiazole (DBD-F) on human gastric cancer cells was examined using both in vitro and in vivo assays.

METHODS AND RESULTS

We found that DBD-F can induce apoptosis and inhibit the mobility of MKN28 and MKN45 gastric cancer-derived cells in vitro. We also found that DBD-F can suppress tumor growth in established gastric cancer-derived xenograft models in vivo. Finally, we found that DBD-F can inhibit HIF2α expression in gastric cancer-derived cells.

CONCLUSIONS

From our findings we conclude that DBD-F (i) is cytotoxic to gastric cancer-derived cells and (ii) can induce apoptosis in these cells via the MEK/ERK signaling pathway. In addition, our findings strongly indicate that DBD-F can inhibit HIF2α expression by affecting the phosphorylation status of MEK/ERK in gastric cancer-derived cells.

Prognostic value of circulating CD133(+) cells in patients with gastric cancer

OBJECTIVES

Gastric cancer is an important cause of cancer-related mortality worldwide (1). There is increasing evidence that the existence of cancer stem cells (CSC) is responsible for tumour formation and maintenance.

MATERIALS AND METHODS

The present study was designed to recognise circulating CSCs from blood samples of patients with gastric cancer, using CD133 and ABCG2 as potential markers. CD133(-) , CD133(+)  ABCG2(-) and CD133(+)  ABCG2(+) cells lines were analysed by flow cytometry, immunofluorescence staining, western blotting and real-time PCR. Furthermore, functional assays (clonogenic assay in vitro and tumourigenic assay in vivo) were also performed using these cell lines.

RESULTS

Higher percentages of CD133(+) cells were identified in blood samples from gastric cancer patients compared to normal controls. In addition, we found by using Kaplan-Meier analysis, that numbers of CD133(+) cells correlated with poor prognosis gastric cancer patients. Finally, tumourigenic properties of CD133(+)  ABCG2(+) cells were determined in vitro and in vivo.

CONCLUSIONS

Our in vitro and in vivo experiments demonstrated that CD133(+)  ABCG2(+) cells exhibited well-known CSC characteristics; thus when circulating they could be used as a prognostic marker for gastric cancer.

Effect of complication grade on survival following curative gastrectomy for carcinoma

AIM

To elucidate the potential impact of the grade of complications on long-term survival of gastric cancer patients after curative surgery.

METHODS

A total of 751 gastric cancer patients who underwent curative gastrectomy between January 2002 and December 2006 in our center were enrolled in this study. Patients were divided into four groups: no complications, Grade I, Grade II and Grade III complications, according to the following classification systems: T92 (Toronto 1992 or Clavien), Accordion Classification, and Revised Accordion Classification. Clinicopathological features were compared among the four groups and potential prognostic factors were analyzed. The Log-rank test was used to assess statistical differences between the groups. Independent prognostic factors were identified using the Cox proportional hazards regression model. Stratified analysis was used to investigate the impact of complications of each grade on survival.

RESULTS

Significant differences were found among the four groups in age, sex, other diseases (including hypertension, diabetes and chronic obstructive pulmonary disease), body mass index (BMI), intraoperative blood loss, tumor location, extranodal metastasis, lymph node metastasis, tumor-node-metastasis (TNM) stage, and chemotherapy. Overall survival (OS) was significantly influenced by the complication grade. The 5-year OS rates were 43.0%, 42.5%, 25.5% and 9.6% for no complications, and Grade I, Grade II and Grade III complications, respectively (P < 0.001). Age, tumor size, intraoperative blood loss, lymph node metastasis, TNM stage and complication grade were independent prognostic factors in multivariate analysis. With stratified analysis, lymph node metastasis, tumor size, and intraoperative blood loss were independent prognostic factors for Grade I complications (P < 0.001, P = 0.031, P = 0.030). Age and lymph node metastasis were found to be independent prognostic factors for OS of gastric cancer patients with Grade II complications (P = 0.034, P = 0.001). Intraoperative blood loss, TNM stage, and chemotherapy were independent prognostic factors for OS of gastric cancer patients with Grade III complications (P = 0.003, P = 0.005, P < 0.001). There were significant differences among patients with Grade I, Grade II and Grade III complications in TNM stage II and III cancer (P < 0.001, P = 0.001).

CONCLUSION

Complication grade may be an independent prognostic factor for gastric cancer following curative resection. Treatment of complications can improve the long-term outcome of gastric cancer patients.

CD147 expression in human gastric cancer is associated with tumor recurrence and prognosis

CD147 is correlated with tumor aggressiveness in various human malignancies. Here, we investigated CD147 protein expression in 223 patients with gastric cancer by immunohistochemistry and analyzed its association with disease-free and overall survival. CD147 was increased in gastric cancer compared to normal tissues. Additionally, CD147 expression was associated with gastric cancer invasion, metastasis and TNM stage, whereas it was not related to age, sex, differentiation status, tumor site or Lauren classification. Kaplan-Meier analysis confirmed that CD147 was associated with disease-free and overall survival in patients with gastric cancer; i.e., patients with positive CD147 staining tend to have worse disease-free and overall survival. Moreover, Cox's proportional hazards analysis demonstrated that CD147 was an independent marker of disease-free and overall survival for patients with gastric cancer. These results confirm the association of CD147 with gastric cancer invasion and metastasis and prove that CD147 might be an indicator of tumor recurrence and prognosis in gastric cancer.

Diagnosis and evaluation of gastric cancer by positron emission tomography

Gastric cancer is the second leading cause of cancer mortality worldwide. The diagnosis of gastric cancer has been significantly improved with the broad availability of gastrointestinal endoscopy. Effective technologies for accurate staging and quantitative evaluation are still in demand to merit reasonable treatment and better prognosis for the patients presented with advanced disease. Preoperative staging using conventional imaging tools, such as computed tomography (CT) and endoscopic ultrasonography, is inadequate. Positron emission tomography (PET), using (18)F-fluorodeoxyglucose (FDG) as a tracer and integrating CT for anatomic localization, holds a promise to detect unsuspected metastasis and has been extensively used in a variety of malignancies. However, the value of FDG PET/CT in diagnosis and evaluation of gastric cancer is still controversial. This article reviews the current literature in diagnosis, staging, response evaluation, and relapse monitoring of gastric cancer, and discusses the current understanding, improvement, and future prospects in this area.

Perioperative chemotherapy in locally advanced gastric cancer

Gastric cancer is one of the most common cancers and a main cause of cancer-related death worldwide, since the majority of patients suffering of this malignancy are usually faced with a poor prognosis due to diagnosis at later stages. In order to improve treatment outcomes, the association of surgery with chemo and/or radiotherapy (multimodal therapy) has become the standard treatment for locally advanced stages. However, despite several treatment options currently available for management of these tumors, perioperative chemotherapy has been mainly accepted for the comprehensive therapeutic strategy including an appropriated D2-gastrectomy. This manuscript presents a (nonsystematic) critical review about the use of perioperative chemotherapy, with a special focus on the drugs delivery.

Laparoscopic gastrectomy for gastric cancer with peritoneal dissemination after induction chemotherapy

Gastric cancer with peritoneal dissemination may be diagnosed as unresectable. More recently, as a result of progress in chemotherapy, some patients with peritoneal dissemination have exhibited extended survival. We report on our experience with three patients in whom induction chemotherapy allowed for totally laparoscopic total gastrectomy (TLTG). All three patients were diagnosed as having advanced gastric cancer with peritoneal dissemination using staging laparoscopy. As induction chemotherapy, S-1 combined with cisplatin was administered to two patients and trastuzumab plus capecitabine combined with cisplatin to one patient. TLTG was performed in all patients and there were no postoperative complications. Adjuvant chemotherapy was initiated within 3 weeks after surgery in all three patients. Laparoscopic gastrectomy undertaken after induction chemotherapy was found to be effective and safe; this treatment has the potential to achieve good treatment outcomes in patients with stage IV gastric cancer.

[Multimodal oncological therapy concepts, chemotherapy and immunosuppressive drugs: effects on surgical morbidity and mortality]

Systemic chemotherapy, targeted therapies and radiotherapy for patients with malignant tumors lead to unfavorable surgical conditions with increased risks of postoperative complications. For gastric cancer and cancer of the esophagogastric junction, surgery after neoadjuvant treatment is associated with a mortality of approximately 5 %. Given the increase in metastatic surgery for colorectal carcinoma, surgeons should be aware of the specific side effects of therapeutic drugs to ensure an optimal course of treatment. The impact of chemotherapy-induced hepatic lesions on postoperative development is unclear. Bevacizumab treatment should be stopped at least 5 weeks before surgery to reduce the risk of thromboembolic events, bleeding and wound healing complications. Immunosuppressive and immunomodulating agents alter wound healing and preoperative alterations should be carefully evaluated. For patients with chronic corticosteroid therapy, perioperative supplementation should be considered when planning surgery as well as routine dosages.

Is there an optimal surgery time after endoscopic resection in early gastric cancer?

BACKGROUND

The patients with early gastric cancer who have undergone incomplete endoscopic resection (ER) generally need additional surgery because of the possibility of lymph node metastasis. The aim of study was to evaluate the optimal time interval from ER to additive surgery by evaluating the effect of time interval on the surgical and oncological outcomes.

METHODS

We analyzed 154 patients who underwent additive gastrectomy after incomplete ER at Severance and Gangnam Severance Hospitals. The time interval point, at which operative time and estimated intraoperative blood loss (EBL) of the earlier operation group and the later operation group showed the greatest disparities, was evaluated. The patients were divided into 2 groups according to the time interval point, as the earlier operation group (group A) and the later operation group (group B). We retrospectively evaluated the clinicopathological characteristics and surgical and oncological outcomes.

RESULTS

The greatest difference between operative time and EBL was in the groups who underwent operation before and after 29 days. Of the 154 patients, 78 were in group A (≤29 days) and 76 in group B (>29 days). There were no differences in the clinicopathological characteristics and oncological outcomes except for tumor size. The operative time and EBL were significantly longer and more in group A compared with group B.

CONCLUSIONS

The time interval between ER and additive surgery is associated with surgical outcomes. Additive surgery at about 1 month after ER may be optimal for better surgical outcomes without affecting the oncological outcomes.

D2 lymphadenectomy is not only safe but necessary in the era of neoadjuvant chemotherapy

BACKGROUND

Patients with locally advanced resectable gastric cancers are increasingly offered neoadjuvant chemotherapy (NACT) following the MAGIC and REAL-2 trials. However, information on the toxicity of NACT, its effects on perioperative surgical outcomes and tumor response is not widely reported in literature.

METHODS

Analysis of a prospective database of gastric cancer patients undergoing radical D2 gastrectomy over 2 years was performed. Chemotherapy-related toxicity, perioperative outcomes and histopathological responses to NACT were analyzed. The data is presented and compared to a cohort of patients undergoing upfront surgery in the same time period.

RESULTS

In this study, 139 patients (42 female and 97 male patients, median age 53 years) with gastric adenocarcinoma received NACT. Chemotherapy-related toxicity was noted in 32% of patients. Of the 139 patients, 129 underwent gastrectomy with D2 lymphadenectomy, with 12% morbidity and no mortality. Major pathological response of primary tumor was noted in 22 patients (17%). Of these 22 patients, lymph node metastases were noted in 12 patients. The median blood loss and lymph node yield was not significantly different to the 62 patients who underwent upfront surgery. Patients who underwent upfront surgery were older (58 vs. 52 years, P <0.02), had a higher number of distal cancers (63% vs. 82%, P <0.015) and a longer hospital stay (11 vs. 9 days, P <0.001).

CONCLUSIONS

Perioperative outcomes of gastrectomy with D2 lymphadenectomy for locally advanced, resectable gastric cancer were not influenced by NACT. The number of lymph nodes harvested was unaltered by NACT but, more pertinently, metastases to lymph nodes were noted even in patients with a major pathological response of the primary tumor. D2 lymphadenectomy should be performed in all patients irrespective of the degree of response to NACT.