Neoadjuvant chemotherapy followed by surgery versus surgery alone for gastric carcinoma: systematic review and meta-analysis of randomized controlled trials

Neoadjuvant Chemotherapy Does Not Improve Survival in cT2N0M0 Gastric Adenocarcinoma Patients: A Multicenter Propensity Score Analysis

BACKGROUND

According to current international guidelines, stage cT2N0M0 gastric adenocarcinoma warrants preoperative chemotherapy followed by surgery. However, upfront surgery is often preferred in clinical practice, depending on patient clinical status and local treatment preferences.

OBJECTIVE

The aim of the present study was to assess the impact of neoadjuvant chemotherapy in overall survival (OS) and disease-free survival (DFS) of cT2N0M0 patients.

METHODS

A retrospective analysis was performed among 32 centers, including gastric adenocarcinoma patients operated between January 2007 and December 2017. Patients with cT2N0M0 stage were divided into upfront surgery (S) and neoadjuvant chemotherapy followed by surgery (CS) groups. Inverse probability of treatment weighting (IPTW) was used to compensate for baseline differences between the groups.

RESULTS

Among the 202 patients diagnosed with cT2N0M0 stage, 68 (33.7%) were in the CS group and 134 (66.3%) were in the S group. CS patients were younger (mean age 62.7 ± 12.8 vs. 69.8 ± 12.1 years for S patients; p < 0.001) and had a better health status (World Health Organization performance status = 0 in 60.3% of CS patients vs. 34.5% of S patients; p = 0.006). During follow-up, recurrence occurred in 27.2% and 19.6% of CS and S patients, respectively, after IPTW (p = 0.32). Five-year OS was similar between CS and S patients (78.9% vs. 68.3%; p = 0.42), as was 5-year DFS (70.4% vs. 68.5%; p = 0.96). Neoadjuvant chemotherapy was associated with neither OS nor DFS in multivariable analysis after IPTW.

CONCLUSIONS

Patients with cT2N0M0 gastric adenocarcinoma did not present a survival or recurrence benefit if treated with perioperative chemotherapy followed by surgery as opposed to surgery alone.

Uncovering the Impact of Lymphadenectomy in Advanced Gastric Cancer: A Comprehensive Review

Gastric cancer is a significant health concern worldwide, and lymphadenectomy plays a crucial role in its treatment. However, there is ongoing debate regarding the optimal approach-D1 or D2 lymphadenectomy. This paper aims to synthesize the available evidence by conducting a comprehensive literature review and comparing the advantages and disadvantages of both techniques. The analysis includes studies, clinical trials, and systematic reviews that assess survival outcomes, morbidity, and quality of life. The selected studies revealed different outcomes associated with D1 and D2 lymphadenectomy, including lymph node harvest, disease control, recurrence rates, and overall survival. Postoperative complications also varied between the two techniques. These findings highlight the complex considerations involved in selecting the most suitable lymphadenectomy approach for individual patients. Therefore, the decision requires an individualized assessment that considers the potential benefits and risks of D1 and D2 techniques. A collaborative approach involving interdisciplinary teams is crucial for developing personalized treatment plans that optimize both oncological outcomes and postoperative quality of life.

The impact of preoperative waiting time in Stage II-III gastric or gastroesophageal junction cancer: A population-based cohort study

BACKGROUND

Gastrectomy remains the curative option in gastric cancer. However, the growing concern that preoperative waiting jeopardizes survival has not been fully addressed. The present population-based cohort study aimed to clarify the impact of preoperative waiting time (PreWT).

METHODS

We included patients with clinical Stage II-III gastric cancer who received curative surgery from 2008 to 2017 of Taiwan Cancer Registry. PreWT was defined as the time from endoscopic diagnosis to surgery. The prognostic impact on overall survival (OS) was evaluated with Cox and restricted cubic spline regressions.

RESULTS

A total of 3059 patients with a median age of 68 years were evaluated. The median PreWT was 16 days (interquartile range, 11-24 days), and patients with a shorter PreWT were younger, had a more advanced disease and received adjuvant therapies. Despite a shorter OS occurring with prolonged PreWT (median OS by PreWT [days]: 7-13, 2.7 years; 14-20, 3.1 years; 21-27, 3.0 years; 28-34, 4.7 years; 35-31, 3.7 years; 42-48, 3.4 years; 49-118, 2.8 years; p = 0.029), the differences were not significant after adjustment. The Cox and restricted cubic spline regressions showed that prolonged PreWT was not a significant prognostic factor for OS (p = 0.719).

CONCLUSIONS

The population-based study suggests that a PreWT of 49-118 days does not independently correlate with a poor prognosis in Stage II-III gastric cancer. The study provides rationale for a window period for preoperative therapies and patient optimization.

Systematic review and meta-analysis of the outcomes following neoadjuvant therapy in upfront resectable gastric cancers compared to surgery alone in phase III randomised controlled trials

BACKGROUND

Gastric cancer is the fifth most common malignancy and the fourth most common cause of cancer mortality globally. The role of neoadjuvant chemotherapy in upfront resectable gastric cancer is a subject of ongoing research. In recent meta-analyses, R0 resection rate and superior outcomes were not consistently observed in such regimens.

AIM

To describe the outcomes following phase III randomised control trials; comparing neoadjuvant therapy followed by surgery against upfront surgery with and without adjuvant therapy in resectable gastric cancers.

METHODS

The Cochrane Library, CINAHL, EMBASE, PubMed, SCOPUS and Web of Science was searched from January 2002 to September 2022.

RESULTS

13 studies were included (3280 participants). R0 resection rates were in neoadjuvant therapy arms as compared to adjuvant therapy with odds ratio (OR) 1.55[95% CI: 1.13, 2.13](p=0.007) and compared to surgery alone OR 2.49[95% CI: 1.56, 3.96](p=0.0001). 3-year and 5-year progression-, event- and disease-free survival in neoadjuvant therapy as compared to adjuvant therapy were not significantly increased, 3-year OR 0.87[0.71, 1.07](p=0.19). Meanwhile, comparing neoadjuvant therapy to adjuvant therapy, 3-year overall survival (OS) hazard ratio was 0.88[95% CI: 0.70, 1.11](p=0.71) while 3- and 5-year OS OR was 1.18[95% CI: 0.90, 1.55], p=0.22 and 1.27[95% CI: 0.67, 2.42](p=0.47) respectively. Surgical complications were also more common with neoadjuvant therapy.

CONCLUSION

Neoadjuvant therapy yields higher rates of R0 resection. However, improved long-term survival was not seen as compared to adjuvant therapy. Large multi-centred randomised control trials with D2 lymphadenectomy should be performed to better evaluate the treatment modalities.

Increased CD4/CD8 Lymphocyte ratio predicts favourable neoadjuvant treatment response in gastric cancer: A prospective pilot study

BACKGROUND

Despite optimal neoadjuvant chemotherapy only 40% of gastric cancer tumours achieve complete or partial treatment response. In the absence of treatment response, neoadjuvant chemotherapy in gastric cancer contributes to adverse events without additional survival benefit compared to adjuvant treatment or surgery alone. Additional strategies and methods are required to optimize the allocation of existing treatment regimens such as FLOT chemotherapy (5-Fluorouracil, Leucovorin, Oxaliplatin and Docetaxel). Predictive biomarkers detected using immunohistochemistry (IHC) methods may provide useful data regarding treatment response.

AIM

To investigate the utility of CD4, CD8, Galectin-3 and E-cadherin in predicting neoadjuvant FLOT chemotherapy tumour response in gastric adenocarcinoma.

METHODS

Forty-three adult patients with gastric adenocarcinoma, of which 18 underwent neoadjuvant chemotherapy, were included in a prospective clinical cohort. Endoscopic biopsies were obtained from gastric cancer and normal adjacent gastric mucosa. Differences in expression of Galectin-3, E-cadherin, CD4⁺ and CD8⁺ molecules between tumours with and without treatment response to neoadjuvant chemotherapy were assessed with IHC. Treatment response was graded by clinical pathologists using the Tumour Regression Score according to the College of American Pathologists criteria. Treatment response was defined as complete or near complete tumour response, whereas partial or poor/no response was defined as incomplete. Digital IHC images were annotated and quantitatively assessed using QuPath 0.3.1. Biomarker expression between responsive and incomplete response tumours was assessed using a two-sided Wilcoxon test. Biomarker expression was also compared between normal and cancer tissue and between 15 paired tumour samples before and after chemotherapy. We performed a preliminary multivariate analysis and power analysis to guide future study. Statistical analyses were completed using R 4.1.2.

RESULTS

The ratio between CD4⁺ and CD8⁺ lymphocytes was significantly greater in treatment responsive tumours (Wilcoxon, P = 0.03). In univariate models, CD4⁺/CD8⁺ ratio was the only biomarker that significantly predicted favourable treatment response (Accuracy 86%, P < 0.001). Using a glmnet multivariate model, high CD4⁺/CD8⁺ ratio and low Galectin-3 expression were the most influential variables in predicting a favourable treatment response. Analyses of paired samples found that FLOT chemotherapy also results in increased expression of CD4⁺ and CD8⁺ tumour infiltrating lymphocytes (Paired Wilcoxon, P = 0.002 and P = 0.008, respectively). Our power analysis suggests future study requires at least 35 patients in each treatment response group for CD8 and Galectin-3 molecules, whereas 80 patients in each treatment response group are required to assess CD4 and E-cadherin biomarkers.

CONCLUSION

We demonstrate that an elevated CD4⁺/CD8⁺ Ratio is a promising IHC-based biomarker to predict favourable treatment response to FLOT neoadjuvant chemotherapy in locally advanced gastric cancer.

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.

Brain metastasis from gastric adenocarcinoma: A large comprehensive population-based cohort study on risk factors and prognosis

Aims

Although brain metastasis from gastric adenocarcinoma (GaC) is rare, it may significantly affect survival and quality of life. The aim of this large, comprehensive, population-based cohort investigation was to investigate factors that were associated with brain metastasis from GaC and to explore the prognostic factors and time-dependent cumulative mortalities among cases with GaC and brain involvement.

Methods

Population-based information on cases with GaC diagnosed from 2010 to 2016 was obtained from a large-scale database. Factors that were associated with brain metastasis were investigated utilizing multivariable logistic regression. Time-dependent tumor-specific mortalities of cases with GaC and brain involvement were then computed utilizing the cumulative incidence functions (CIFs), and mortalities were compared between subgroups utilizing Gray's test. Factors that were associated with death were further evaluated utilizing multivariable Fine-Gray subdistribution hazard regression.

Results

Together, 28,736 eligible cases were included, which comprised 231 (1%) cases with brain metastasis and 10,801 (38%) with metastasis to other sites, encompassing a follow-up of 39,168 person-years. Brain metastasis occurred more often among younger patients (within overall cancers), in cases with stomach cardia tumors, within cases with signet-ring cell carcinoma (within overall cancers), and within cases with positive lymph nodes (within overall tumors); it was less often detected among black people. Brain involvement was associated with more lung and bone metastases. The median survival time of cases having brain metastasis was only 3 months; the 6- and 12-month tumor-specific cumulative mortalities were 57% and 71%, respectively. Among cases with GaC and brain metastasis, those with gastric cardia cancers (when receiving radiotherapy), those undergoing resection, and those receiving chemotherapy had lower mortality risks, while younger patients (when receiving chemotherapy or radiotherapy) and people with positive lymph nodes (when receiving radiotherapy) had higher death hazards.

Conclusion

Among patients with GaC, brain metastasis was correlated with several clinical and pathological variables, including ethnicity, age, cancer histology, location, lymph node involvement, and metastases to other sites. Cases having brain metastasis had poor survival that was correlated with age, cancer location, lymph node metastasis, and management. These findings offer vital clues for individualized patient care and future mechanistic explorations.

Comparison of response evaluation criteria in solid tumors and tumor regression grade in evaluating the effect of preoperative systemic therapy of gastric cancer

BACKGROUND

Both Response Evaluation Criteria in Solid Tumors (RECIST) and tumor regression grade (TRG) play key roles in evaluating tumor response. We analyzed the consistency of TRG and RECIST 1.1 for gastric cancer (GC) patients and compared their prognostic values.

METHODS

Patients with GC who received preoperative chemotherapy or chemoimmunotherapy and had records of TRG from December 2013 to October 2021 were enrolled retrospectively. TRG 0-1 and 2-3 are considered as corresponding to complete response (CR)/partial response (PR) and stable disease (SD)/progress disease (PD) in RECIST 1.1, respectively. The primary endpoints were disease-free survival (DFS) and overall survival (OS). The consistency of RECIST and TRG was examined by kappa statistics. Survival analysis was performed using the Kaplan Meier method.

RESULT

One hundred fifty seven GC patients were enrolled, including 125 with preoperative chemotherapy and 32 with chemoimmunotherapy. Among them, 56 patients had measurable lesions. Only 19.6% (11/56) of the patients had consistent results between RECIST 1.1 and TRG. TRG was correlated with both OS and DFS (P = 0.02 and 0.03, respectively) while response according to RECIST1.1 was not (P = 0.86 and 0.23, respectively). The median DFS had not reached in the TRG 0-1 group and was 16.13 months in TRG 2-3 group. TRG 2-3 was associated with young age and peritoneal or liver metastasis. Besides, preoperative chemoimmunotherapy had a significantly higher pCR rate than chemotherapy alone (34.4% vs 8.0%, P < 0.001).

CONCLUSION

TRG was in poor agreement with RECIST 1.1. TRG was better than RECIST 1.1 in predicting DFS and OS for GC patients who received preoperative therapy.

Enhanced CT-based radiomics predicts pathological complete response after neoadjuvant chemotherapy for advanced adenocarcinoma of the esophagogastric junction: a two-center study

Purpose

This study aimed to develop and validate CT-based models to predict pathological complete response (pCR) after neoadjuvant chemotherapy (NAC) for advanced adenocarcinoma of the esophagogastric junction (AEG).

Methods

Pre-NAC clinical and imaging data of AEG patients who underwent surgical resection after preoperative-NAC at two centers were retrospectively collected from November 2014 to September 2020. The dataset included training (n = 60) and external validation groups (n = 32). Three models, including CT-based radiomics, clinical and radiomics–clinical combined models, were established to differentiate pCR (tumor regression grade (TRG) = grade 0) and nonpCR (TRG = grade 1–3) patients. For the radiomics model, tumor-region-based radiomics features in the arterial and venous phases were extracted and selected. The naïve Bayes classifier was used to establish arterial- and venous-phase radiomics models. The selected candidate clinical factors were used to establish a clinical model, which was further incorporated into the radiomics–clinical combined model. ROC analysis, calibration and decision curves were used to assess the model performance.

Results

For the radiomics model, the AUC values obtained using the venous data were higher than those obtained using the arterial data (training: 0.751 vs. 0.736; validation: 0.768 vs. 0.750). Borrmann typing, tumor thickness and degree of differentiation were utilized to establish the clinical model (AUC-training: 0.753; AUC-validation: 0.848). The combination of arterial- and venous-phase radiomics and clinical factors further improved the discriminatory performance of the model (AUC-training: 0.838; AUC-validation: 0.902). The decision curve reflects the higher net benefit of the combined model.

Conclusion

The combination of CT imaging and clinical factors pre-NAC for advanced AEG could help stratify potential responsiveness to NAC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13244-022-01273-w.

Interplay of Helicobacter pylori, fibroblasts, and cancer cells induces fibroblast activation and serpin E1 expression by cancer cells to promote gastric tumorigenesis

Background

Helicobacter pylori (H. pylori) can disrupt the tight junctions between gastric epithelial cells and penetrate the intercellular spaces acting on epithelial cells, normal fibroblasts (NFs), and cancer-associated fibroblasts (CAFs), but their interaction in gastric cancer tumorigenesis and progression remains unclear.

Methods

Primary CAFs and NFs were isolated from paired gastric cancer tissues and adjacent normal tissues and identified by immunofluorescence staining and western blot analysis for FSP-1, α-SMA, FAP, and vimentin expression. RNA-sequencing was used to compare the transcriptomes between CAFs and NFs. The expressions of FAP, lumican, and α-SMA, human cytokine array, and Transwell assay were used to assess the transformation of NFs to CAFs. CCK-8 assay, colony formation, flow cytometry, Transwell assay, and nude mouse xenograft model were used to determine the effects of Serpin E1 on cell proliferation and metastasis in vitro and in vivo. Finally, Serpin E1 and/or FAP expression was measured in H. pylori-infected gerbil gastric mucosa and human gastric cancer tissues.

Results

Gastric CAFs are inflammatory CAFs with α-SMA^lowFAP^highlumican^high. The interplay of H. pylori, fibroblasts, and cancer cells promotes the transition of NFs to CAFs by inducing cytokine release, especially Serpin E1. Long-term H. pylori infection and CAFs induce Serpin E1 expression in gerbil gastric tissues and human gastric cancer cells. Serpin E1 overexpression enhances the growth, migration, invasion of gastric cancer cells in vitro, and xenograft tumor growth in nude mice via inducing angiogenesis. Serpin E1 and FAP were highly expressed in cancer cells and CAFs of gastric cancer tissues, respectively, and a good correlation was observed between their expression. Higher Serpin E1 expression is negatively associated with the overall survival of patients with gastric cancer.

Conclusions

The interplay of H. pylori, fibroblasts, and cancer cells induced Serpin E1 expression to promote the activation of NFs to CAFs and gastric carcinogenesis. Targeting Serpin E1 will provide a promising therapeutic strategy for gastric cancer by disrupting the interaction between H. pylori, CAFs, and gastric cancer cells.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12967-022-03537-x.

Role of Neoadjuvant Chemotherapy in Locally Advanced Carcinoma Stomach: An Analysis of the Short-Term Outcomes

Introduction: Neoadjuvant chemotherapy (NACT) in carcinoma stomach was introduced in an effort to eliminate micro-metastasis and to improve resectablity before surgery which improves R0 resection rates. We aimed to study the short term outcomes of neoadjuvant chemotherapy on the Tumor Node Metastasis (TNM) stage and the operative outcomes including R0 resection rate in locally advanced gastric cancer.

Methods: We prospectively included patients with locally advanced adenocarcinoma stomach staged by contrast-enhanced computed tomography (CECT) in our study. Patients in Group I were started on neoadjuvant chemotherapy (epirubicin, oxaliplatin, and capecitabine). Surgery was done following response assessment CECT. Patients in Group II underwent upfront surgery. We assessed R0 resection rate, number of harvested and metastatic lymph nodes, lymph node ratio, duration of surgery, blood loss, hospital stay and complications between two groups. Response to NACT was assessed in Group I.

Results: Out of 47 patients who received NACT, two patients had complete response (4.2%), 13 had partial response (27.7%), 10 had stable disease (21.3%) and 22 patients had progressive disease (46.8%). We found no significant difference in the rate of R0 resection between the two groups (88.2% in NACT group vs 85.1% in surgery group, P=0.55).

Conclusions: The rate of R0 resection does not significantly improve with neoadjuvant chemotherapy. In view of high progression rates, patient selection is required when NACT is planned in carcinoma stomach which are surgically resectable at presentation. We await survival analysis to further validate the role of NACT.

Neoadjuvant Treatment Strategies for Resectable Proximal Gastric, Gastroesophageal Junction and Distal Esophageal Cancer

Simple Summary

The five-year survival for resectable proximal gastric, gastroesophageal junction (GEJ), and distal esophageal cancer ranges from 30 to 60% globally. Neoadjuvant and/or perioperative therapy has emerged as a treatment tool to improve patient selection for surgery, resectability, and locoregional control of the disease. As a result, treatment strategies have evolved from the first trials in the late 1980s to the pivotal CROSS trial updated in 2015. The review summarizes current clinical trials and treatment recommendations with regard to neoadjuvant and/or perioperative therapy for patients with adenocarcinoma and squamous cell carcinoma of the distal esophagus, GEJ, and proximal stomach.

Abstract

Neoadjuvant treatment strategies for resectable proximal gastric, gastroesophageal junction (GEJ), and distal esophageal cancer have evolved over several decades. Treatment recommendations differ based on histologic type—squamous cell carcinoma (SCC) versus adenocarcinoma (AC)—as well as the exact location of the tumor. Recent and older clinical trials in this area were critically reviewed. Neoadjuvant chemoradiation with concurrent taxane- or fluoropyrimidine-based chemotherapy has an established role for both AC and SCC of the distal esophagus and GEJ. The use of perioperative chemotherapy for gastric AC is based on the FLOT4 and MAGIC trials; however, the utility of neoadjuvant chemoradiation in this setting requires further evaluation. Additional clinical trials evaluating chemotherapy, targeted therapy, immunotherapy, and radiation that are currently in process are highlighted, given the need for further disease control.

5,7,2,5-tetrahydroxy-8,6-dimethoxyflavone up-regulates miR-145 expression and inhibits proliferation of gastric cancer cells

INTRODUCTION

Gastric cancer is a frequently detected malignancy, and its incidence has increased over the past decades in East Asia. The present study investigated the effect of 5,7,2, 5-tetrahydroxy-8,6-dimethoxyflavone (THDMF) on gastric cancer cells and explored the underlying mechanism. The study analysed cell viability changes, apoptotic features, and metastasis potential of treatment with THDMF.

MATERIAL AND METHODS

MTT colorimetric assay was used for measurement of MKN28, MKN45, and GES-1 cell proliferation and flow cytometry for the detection of apoptosis. Transwell and wound healing assays were used to observe the invasion and migration abilities of MKN28 cells. The expression of p21, MMP2/-9, PI3K, and c-Myc proteins was detected by western blotting.

RESULTS

The THDMF treatment significantly (p < 0.05) reduced MKN28 and MKN45 cell proliferation without changing GES-1 cell viability. A significant increase in apoptotic cell population on treatment with THDMF was observed. Treatment of MKN28 cells with THDMF increased the percentage of cells in the G1 phase. Exposure of MKN28 cells to THDMF caused a marked decrease in invasion and migration potential in comparison to control cells. The expression of miR-145 was markedly increased in MKN28 cells on treatment with THDMF. In MKN28 cells expression of c-Myc, PI3K, p-AKT, MMP-2, and MMP-9 was suppressed markedly on exposure to THDMF. The expression of p21 protein in MKN28 cells was markedly promoted on exposure to THDMF.

CONCLUSIONS

THDMF exhibits anti-cancer effect on gastric cancer cells in vitro by activation of cell apoptosis and arrest of cell cycle. In addition, THDMF promoted miR-145 expression and down-regulation of PI3K/AKT signalling pathway in MKN28 cells. Therefore, THDMF may be utilised as a potential novel therapeutic agent for the treatment of gastric cancer.

Impact of neoadjuvant therapy followed by laparoscopic radical gastrectomy with D2 lymph node dissection in Western population: A multi-institutional propensity score-matched study

Background and Objectives

In the setting of a minimally invasive approach, we aimed to compare short and long‐term postoperative outcomes of patients treated with neoadjuvant therapy (NAT) + surgery or upfront surgery in Western population.

Methods

All consecutive patients from six Italian and one Serbian center with locally advanced gastric cancer who had undergone laparoscopic gastrectomy with D2 lymph node dissection were selected between 2005 and 2019. After propensity score‐matching, postoperative morbidity and oncologic outcomes were investigated.

Results

After matching, 97 patients were allocated in each cohort with a mean age of 69.4 and 70.5 years. The two groups showed no difference in operative details except for a higher conversion rate in the NAT group (p = 0.038). The overall postoperative complications rate significantly differed between NAT + surgery (38.1%) and US (21.6%) group (p = 0.019). NAT was found to be related to a higher risk of postoperative morbidity in patients older than 60 years old (p = 0.013) but not in patients younger (p = 0.620). Conversely, no difference in overall survival (p = 0.41) and disease‐free‐survival (p = 0.34) was found between groups.

Conclusions

NAT appears to be related to a higher postoperative complication rate and equivalent oncological outcomes when compared with surgery alone. However, poor short‐term outcomes are more evident in patients over 60 years old receiving NAT.

Comparison of neoadjuvant chemotherapy followed by surgery vs. surgery alone for locally advanced gastric cancer: a meta-analysis

BACKGROUND

The neoadjuvant chemotherapy is increasingly used in advanced gastric cancer, but the effects on safety and survival are still controversial. The objective of this meta-analysis was to compare the overall survival and short-term surgical outcomes between neoadjuvant chemotherapy followed by surgery (NACS) and surgery alone (SA) for locally advanced gastric cancer.

METHODS

Databases (PubMed, Embase, Web of Science, Cochrane Library, and Google Scholar) were explored for relative studies from January 2000 to January 2021. The quality of randomized controlled trials and cohort studies was evaluated using the modified Jadad scoring system and the Newcastle-Ottawa scale, respectively. The Review Manager software (version 5.3) was used to perform this meta-analysis. The overall survival was evaluated as the primary outcome, while perioperative indicators and post-operative complications were evaluated as the secondary outcomes.

RESULTS

Twenty studies, including 1420 NACS cases and 1942 SA cases, were enrolled. The results showed that there were no significant differences in overall survival (P = 0.240), harvested lymph nodes (P = 0.200), total complications (P = 0.080), and 30-day post-operative mortality (P = 0.490) between the NACS and SA groups. However, the NACS group was associated with a longer operation time (P < 0.0001), a higher R0 resection rate (P = 0.003), less reoperation (P = 0.030), and less anastomotic leakage (P = 0.007) compared with SA group.

CONCLUSIONS

Compared with SA, NACS was considered safe and feasible for improved R0 resection rate as well as decreased reoperation and anastomotic leakage. While unbenefited overall survival indicated a less important effect of NACS on long-term oncological outcomes.

Delta-radiomics and response to neoadjuvant treatment in locally advanced gastric cancer-a multicenter study of GIRCG (Italian Research Group for Gastric Cancer)

Background

To predict response to neoadjuvant chemotherapy (NAC) of gastric cancer (GC), prior to surgery, would be pivotal to customize patient treatment. The aim of this study is to investigate the reliability of computed tomography (CT) texture analysis (TA) in predicting the histo-pathological response to NAC in patients with resectable locally advanced gastric cancer (AGC).

Methods

Seventy (40 male, mean age 63.3 years) patients with resectable locally AGC, treated with NAC and radical surgery, were included in this retrospective study from 5 centers of the Italian Research Group for Gastric Cancer (GIRCG). Population was divided into two groups: 29 patients from one center (internal cohort for model development and internal validation) and 41 from other four centers (external cohort for independent external validation). Gross tumor volume (GTV) was segmented on each pre- and post-NAC multidetector CT (MDCT) image by using a dedicated software (RayStation), and 14 TA parameters were then extrapolated. Correlation between TA parameters and complete pathological response (tumor regression grade, TRG1), was initially investigated for the internal cohort. The univariate significant variables were tested on the external cohort and multivariate logistic analysis was performed.

Results

In multivariate logistic regression the only significant TA variable was delta gray-level co-occurrence matrix (GLCM) contrast (P=0.001, Nagelkerke R²: 0.546 for the internal cohort and P=0.014, Nagelkerke R²: 0.435 for the external cohort). Receiver operating characteristic (ROC) curves, generated from the logistic regression of all the patients, showed an area under the curve (AUC) of 0.763.

Conclusions

Post-NAC GLCM contrast and dissimilarity and delta GLCM contrast TA parameters seem to be reliable for identifying patients with locally AGC responder to NAC.

Prediction Model of Tumor Regression Grade for Advanced Gastric Cancer After Preoperative Chemotherapy

Background

Preoperative chemotherapy (PCT) has been considered an important treatment for advanced gastric cancer (AGC). The tumor regression grade (TRG) system is an effective tool for the assessment of patient responses to PCT. Pathological complete response (TRG = 0) of the primary tumor is an excellent predictor of better prognosis. However, which patients could achieve pathological complete response (TRG = 0) after chemotherapy is still unknown. The study aimed to find predictors of TRG = 0 in AGC.

Methods

A total of 304 patients with advanced gastric cancer from July 2009 to November 2018 were enrolled retrospectively. All patients were randomly assigned (2:1) to training and internal validation groups. In addition, 124 AGC patients receiving PCT from December 2018 to June 2020 were included prospectively in the external validation cohort. A prediction model for TRG = 0 was established based on four predictors in the training group and was validated in the internal and external validation groups.

Results

Through univariate and multivariate analyses, we found that CA199, CA724, tumor differentiation and short axis of the largest regional lymph node (LNmax) were independent predictors of TRG = 0. Based on the four predictors, we established a prediction model for TRG = 0. The AUC values of the prediction model in the training, internal and external validation groups were 0.84, 0.73 and 0.82, respectively.

Conclusions

We found that CA199, CA724, tumor differentiation and LNmax were associated with pathological response in advanced gastric cancer. The prediction model could provide guidance for clinical work.

Body Composition Changes in Gastric Cancer Patients during Preoperative FLOT Therapy: Preliminary Results of an Italian Cohort Study

Background: The impact of the new chemotherapy, fluorouracil plus leucovorin, oxaliplatin, and docetaxel (FLOT) on body composition in gastric cancer (GC) patients remains unknown. We assessed body composition changes of GC patients receiving the FLOT regimen and their impact on treatment outcomes. Methods: Preoperative pre- and post-FLOT computed tomography (CT) scans of advanced GC patients were studied. Lumbar skeletal muscle index (SMI) and adipose indices were calculated before and after FLOT. Results: A total of 26 patients were identified between April 2019 and January 2020. Nineteen patients were sarcopenic at diagnosis. The mean BMI decreased (from 24.4 ± 3.7 to 22.6 ± 3.1; p < 0.0001) as well as the SMI (from 48.74 ± 9.76 to 46.52 ± 9.98; p = 0.009) and visceral adipose index (VAI) (from 49.04 ± 31.06 to 41.99 ± 23.91; p = 0.004) during preoperative FLOT therapy. BMI, SMI, and VAI variations were not associated with toxicity, Response Evaluation Criteria in Solid Tumors (RECIST), response, delay and completion of perioperative FLOT chemotherapy, and the execution of gastrectomy; a decrease of SMI ≥ 5% was associated with a higher Mandard tumor regression grade (p = 0.01). Conclusions: Almost three-quarters (73.1%) of GC patients were sarcopenic at diagnosis. Preoperative FLOT was associated with a further reduction in SMI, BMI, and VAI. These changes were not associated with short-term outcomes.

Prediction model of objective response after neoadjuvant chemotherapy in patients with locally advanced gastric cancer

BACKGROUND

Neoadjuvant chemotherapy (NAC) plays an important role in the therapeutic strategy of locally advanced gastric cancer (LAGC). However, the response of LAGC after NAC varies among different patients. The objective response after NAC has proven to be an excellent indicator for benefiting from NAC, yet effective predictors of objective response are still lacking. The present study aimed to identify potential predictors of objective response in LAGC patients treated with NAC.

METHODS

Clinicopathological data from 267 patients with LAGC who received NAC and met the inclusion criteria between July 2009 and December 2018 were retrospectively reviewed. Patients were randomly divided into the training and test sets at a 2:1 ratio. Univariate analysis was used to investigate whether any factors were correlated with objective response in the training set. Multivariate logistic regression analysis was applied to find independent predictors. A risk score model was then constructed based on the independent predictors, and its performance in predicting objective response was validated in the test set.

RESULTS

Univariate analysis found that gender, age, short axis diameter of the largest regional lymph node (LN_max), serum total protein content, CEA detection value, tumor location, tumor differentiation, signet ring cell carcinoma component and Borrmann type were potential predictors for objective response. In multivariate logistic regression analysis, gender, LN_max and signet ring cell carcinoma component were independent predictors for objective response. Based on independent predictors, we developed a prediction model for objective response.

CONCLUSIONS

We found gender, LN_max and signet ring cell carcinoma component were independent predictors for objective response. The prediction model is a good tool to predict the objective response for LAGC patients treated with NAC, which can be applied to guide clinical practice.

Treatment Patterns for Gastroesophageal Junction Adenocarcinoma in the United States

Despite the increasing incidence of gastroesophageal junction adenocarcinoma (GEJA), the optimal treatment strategy for the disease remains unknown. The objective of this study was to describe treatment patterns for GEJA in the United States. The National Cancer Database was searched to identify all patients who underwent resection of the lower esophagus, abdominal esophagus, and/or gastric cardia for GEJA between 2006 and 2016. Patients were grouped by clinical disease stage: early localized (L; T1-2N0), locally advanced (LA; T3-4N0), regional (R; T1-2N+), or regionally advanced (RA; T3-4N+). The search identified 28,852 GEJA patients. The dominant age range was 60–69 years (39%). Most patients were men (85%), and most were white (92%). Most L patients (69%) underwent upfront surgery, whereas most LA, R, and RA patients received neoadjuvant therapy (NAT; 86%, 80%, and 90%, respectively). Among patients who received NAT, 85% received chemoradiotherapy. Adjuvant therapy was relatively uncommon across all groups (15–20%). In the LA, R, and RA groups, overall survival was greater in patients who received NAT compared to upfront surgery (p < 0.001). With the exception of patients with early localized node-negative disease, most GEJA patients receive neoadjuvant chemoradiotherapy despite the lack of prospective trials reporting survival benefit over chemotherapy alone.

Preoperative Staging of Gastric Cancer Using Computed Tomography and Its Correlation with Histopathology with Emphasis on Multi-planar Reformations and Virtual Gastroscopy

BACKGROUND

Gastric cancer is the fifth most common cancer in the world. Preoperative staging of gastric cancer has assumed pivotal role in deciding appropriate management of gastric cancer with multi-detector computed tomography (MDCT) using hydro- and gaseous distension of stomach superseding endoscopic ultrasound in tumor (T) and nodal (N) staging. We undertook this study to evaluate the diagnostic accuracy of MDCT in the T and N staging of gastric cancer with an attempt to differentiate between early and advanced gastric carcinomas.

METHODS

A total of 160 patients with endoscopically diagnosed and biopsy-proven gastric cancer were subjected to MDCT after adequate gaseous and hydro-distention of stomach. Multi-planar reformatted (MPR) as well as virtual gastroscopy images were also obtained. Gastric lesions were categorized into T1 to T4 stages with N staging from N0 to N3. Preoperative CT findings were correlated with histopathological findings.

RESULTS

Overall diagnostic accuracy of T staging in our study was 82.5% (132/160) with an accuracy of 75% (120/160) for N staging. The diagnostic accuracy of CT for early gastric carcinoma in our study was 93.75% with high specificity of 96% but low sensitivity of 66.7%.

CONCLUSION

MDCT using gaseous and hydro-distension of stomach is an excellent modality for near accurate preoperative T staging of gastric cancer. However, CT has a limited role in the N staging of gastric cancer. This study also suggested that the combined use of virtual gastroscopy and MPR images helps in better detection of early gastric cancers.

National trends in total vs subtotal gastrectomy for middle and distal third gastric cancer

BACKGROUND

To identify trends in total and subtotal gastrectomy for middle and distal third gastric adenocarcinoma in the U.S.

METHODS

NCDB was queried for patients with stage 0-III middle or distal gastric adenocarcinoma treated with total or subtotal gastrectomy. Statistical analysis including cox proportional hazards model was performed to examine overall survival by stage.

RESULTS

1,628 (85%) underwent subtotal gastrectomy and 283 (15%) underwent total. 1113 patients (58%) had distal tumors and 798 (42%) had middle tumors. Total gastrectomy patients more often had poor tumor grade (60% vs 50%,p < 0.01), larger size (46.3 mm vs 37.8 mm,p < 0.0001), had positive nodes (3.6 ± 5.9 vs 2.2 ± 4.1,p < 0.0001), underwent chemoradiation (13% vs 6%,p < 0.0001), and were higher clinical stage (p < 0.05). An overall survival curve showed an adjusted HR of 2.7 for total vs subtotal gastrectomy at clinical stage 3 (p < 0.05).

CONCLUSIONS

Total gastrectomy is performed for larger, more aggressive tumors with higher stage. Subtotal gastrectomy may have a survival benefit for stage III gastric cancers.

Docetaxel, oxaliplatin, leucovorin, and 5-fluorouracil (FLOT) as preoperative and postoperative chemotherapy compared with surgery followed by chemotherapy for patients with locally advanced gastric cancer: a propensity score-based analysis

Introduction: Docetaxel, oxaliplatin, leucovorin, and 5-fluorouracil (FLOT) may improve overall survival (OS) in patients with locally advanced gastric cancer (LAGC); however, evidence for its use as a standard treatment has not been established in China. The aim of this study was to investigate the effectiveness, safety, and feasibility of the FLOT regimen as neoadjuvant chemotherapy in Chinese patients with resectable LAGC.

Methods: We conducted an observational study to compare the effectiveness of FLOT regimen consisting of docetaxel (60 mg/m²), oxaliplatin (85 mg/m²), leucovorin (200 mg/m²), and 5-fluorouracil (2,600 mg/m² as a 24 hr infusion), all given on day 1 and administered every 2 weeks versus initial surgery followed by chemotherapy in patients with clinical T3–4 LAGC. OS was compared by using the Cox proportional hazards regression model and the Kaplan–Meier curve adjusted by inverse probability of treatment weighting (IPTW) and propensity score-matched (PSM) analysis. In addition, we performed subgroup analyses to determine the effectiveness of the FLOT regimen in clinically relevant patient subsets.

Results: Overall, 47 patients who received initial FLOT chemotherapy and 269 patients who received initial surgery were enrolled in this study. In the PSM analysis, the FLOT-first group showed favorable OS compared with the surgery-first group (41 vs 41 [HR, 0.416; 95% CI, 0.218–0.794; P=0.008]), and 3-year survival rates were 58.7% and 30.9% in the FLOT-first group and surgery-first group, respectively. IPTW analysis showed similar results. However, the effect of FLOT was low (HR, 0.868; 95 CI%, 0.215–3.504) in patients without lymph node metastasis.

Conclusion: Our study suggests that preoperative FLOT chemotherapy is safe and feasible. In terms of OS, FLOT may be superior to initial surgery followed by chemotherapy in reducing morbidity with resectable LAGC.

Prospective Randomized Controlled Study Comparing Primary Surgery Versus Neoadjuvant Chemotherapy Followed by Surgery in Gastric Carcinoma

Neoadjuvant chemotherapy in gastric cancer can treat micro metastatic disease and can increase the resectability rate. The trial was to compare early outcomes after primary surgery versus neoadjuvant chemotherapy followed by surgery in gastric adenocarcinoma. The primary aim of the study was to compare resectability and R0 resection rates in upfront surgery v/s chemotherapy followed by surgery arm. A secondary aim was to see if neoadjuvant chemotherapy is well tolerated or not by comparing postoperative morbidity and mortality. The study consisted of 60 consecutive patients of carcinoma stomach randomized into primary surgery and neoadjuvant chemotherapy followed by surgery arms. Morbidity, pathological status, and mortality data were collected and analyzed. Mean operating time in primary surgery arm was 290 ± 46.5 min, while in NACTarm, it was 316.7 ± 56.6 min, respectively. When postop complications were compared between the arms, it was not significant. Comparing the histopathological report of two groups, there was no significant difference between differentiated, T stage, mean lymph node harvest, R0 resection, PNI, and LVI. Neoadjuvant chemotherapy showed a trend towards improving in the R0 resection rate. There is no increase in postoperative morbidity and mortality with neoadjuvant chemotherapy.

Effect of miR‑145 on gastric cancer cells

Gastric cancer is one of the most common malignant tumors in the world. Due to the lack of early diagnosis and effective treatment, the outcome of treatment and prognosis is poor. MicroRNA-145 (miR-145) is downregulated in various cancer types. In the present study, miR-145 expression was detected by reverse transcription-quantitative polymerase chain reaction in gastric cancer cell lines and normal gastric epithelial cells. The function of miR-145 in the gastric cancer cell line SGC-7901 was investigated. The present results demonstrated that the expression of miR-145 was downregulated in gastric cancer cells. Further analysis identified that upregulation of miR-145 significantly suppressed SGC-7901 cell proliferation, increased cellular apoptosis and blocked the cell cycle in the G₁ phase. Additionally, overexpression of miR-145 reduced SGC-7901 cell invasion and metastasis in vitro. Western blot analysis demonstrated that overexpression of miR-145 downregulated Myc proto-oncogene protein, phosphoinositide 3-kinase/protein kinase B and matrix metalloproteinase 2/9, and upregulated p21 in SGC-7901 cells. The present results revealed potential signaling pathways that miR-145 may use to regulate gastric cancer cell proliferation, apoptosis and metastasis. Collectively, the present results suggest that miR-145 is a tumor suppressor for gastric cancer and it may be a potential therapeutic target for gastric cancer treatment.

TRIM37 promotes cell invasion and metastasis by regulating SIP1-mediated epithelial-mesenchymal transition in gastric cancer

Background

Tripartite motif containing 37 (TRIM37) has been demonstrated to function importantly during the progression of various cancers. However, the role of TRIM37 in gastric cancer (GC) remains elusive.

Materials and methods

TRIM37 mRNA and protein expressions were determined by qRT-PCR, Western blot, and immunohistochemical staining in GC specimens. The effects of TRIM37 on GC cells behavior were evaluated by transwell assays in vitro and metastasis assay in vivo, respectively. Besides, qRT-PCR, Western blot, and immunofluorescence staining were employed to detect the expressions of TRIM37 and epithelial–mesenchymal transition (EMT)-related markers.

Results

The present study revealed that TRIM37 mRNA or protein expression was significantly increased in GC tissues compared with that in paracancerous control tissues, and its aberrant overexpression was closely associated with clinical metastasis and poor prognosis in patients with GC. TRIM37 knockdown significantly suppressed GC cells migration and invasion in vitro, as well as metastasis in vivo. Inversely, TRIM37 overexpression exerted the opposite effects. Mechanistic studies suggested that SIP1-mediated EMT might be responsible for TRIM37-facilitated GC cells migration and invasion.

Conclusion

Our findings revealed that high TRIM37 expression was associated with clinical metastasis and poor survival in patients with GC. TRIM37 promoted GC cells migration and invasion via EMT, mediated by the transcription factor SIP1, thus providing a candidate target for GC treatment.

Role of Helicobacter pylori infection in cancer-associated fibroblast-induced epithelial-mesenchymal transition in vitro

BACKGROUND

Major human gastrointestinal pathogen Helicobacter pylori (H. pylori) colonizes the gastric mucosa causing inflammation and severe complications including cancer, but the involvement of fibroblasts in the pathogenesis of these disorders in H. pylori-infected stomach has been little studied. Normal stroma contains few fibroblasts, especially myofibroblasts. Their number rapidly increases in the reactive stroma surrounding inflammatory region and neoplastic tissue; however, the interaction between H. pylori and fibroblasts remains unknown. We determined the effect of coincubation of normal rat gastric fibroblasts with alive H. pylori (cagA+vacA+) and H. pylori (cagA-vacA-) strains on the differentiation of these fibroblasts into cells possessing characteristics of cancer-associated fibroblasts (CAFs) able to induce epithelial-mesenchymal transition (EMT) of normal rat gastric epithelial cells (RGM-1).

MATERIALS AND METHODS

The panel of CAFs markers mRNA was analyzed in H. pylori (cagA+vacA+)-infected fibroblasts by RT-PCR. After insert coculture of differentiated fibroblasts with RGM-1 cells from 24 up to 48, 72, and 96 hours, the mRNA expression for EMT-associated genes was analyzed by RT-PCR.

RESULTS

The mRNA expression for CAFs markers was significantly increased after 72 hours of infection with H. pylori (cagA+vacA+) but not H. pylori (cagA-vacA-) strain. Following coculture with CAFs, RGM-1 cells showed significant decrease in E-cadherin mRNA, and the parallel increase in the expression of Twist and Snail transcription factors mRNA was observed along with the overexpression of mRNAs for TGFβR, HGFR, FGFR, N-cadherin, vimentin, α-SMA, VEGF, and integrin-β1.

CONCLUSION

Helicobacter pylori (cagA+vacA+) strain induces differentiation of normal fibroblasts into CAFs, likely to initiate the EMT process in RGM-1 epithelial cell line.

Laparoscopic surgery for gastric cancer: where are we now and where are we going?

INTRODUCTION

Minimally-invasive surgery is gaining increasing popularity for the management of gastric cancer (GC). Areas covered: The authors hereby comprehensively and systematically reviewed the randomized and/or prospective evidence on laparoscopic gastrectomy (LG) for GC. For early GC located in the distal stomach, various randomized trials have demonstrated the superiority/non-inferiority of LG especially in reducing surgical trauma and enhancing postoperative recovery without compromising surgical safety and oncologic efficacy. For advanced GC, while multicenter large-scale randomized evidence has demonstrated the safety and feasibility of LG by experienced hands, the long-term survival which is to be clarified by several ongoing trials are crucial to determine whether a more widespread application is acceptable. Randomized evidence regarding the application of laparoscopic total or proximal gastrectomy, which is technically challenging, is scarce. Various attempts in modification of the traditional laparoscopic approach to further reduce the trauma have been evaluated, such as single-incision and totally LG. LG is becoming increasingly individualized and precise. Expert commentary: The current randomized and/or prospective evidence supports the non-inferiority of laparoscopic surgery especially for the management of early GC located in the distal stomach, while the definitive efficacy of the laparoscopic approach for more surgically challenging situations remains largely explorative and investigative.

Retrospective study on efficacy of a paclitaxel combined with a leucovorin and fluorouracil regimen for advanced gastric cancer

Purpose:

To investigate the efficacy of paclitaxel combined with a leucovorin and 5-fluorouracil regimen (PLF regimen; q2w) as neoadjuvant chemotherapy (NCT) for advanced gastric cancer.

Methods:

A total of 183 patients with advanced gastric cancer who underwent 3 cycles of PLF regimen chemotherapy before surgery and received surgery 2 weeks after chemotherapy were enrolled as a treatment group. A total of 184 patients with advanced gastric cancer and no NCT during the same period were enrolled as the controls and treated with surgery. Both groups underwent a D2 radical gastrectomy and the standard postoperative adjuvant chemotherapy.

Results:

In the NCT group, there were 19 cases of complete remission, 86 cases of partial remission, 72 cases of stable disease, and 6 cases of progressive disease, with an overall response rate of 57.4%. The R0 resection rate was higher than in the control group (85.2% vs 61.4%, p < .05). In the NCT group, 12 cases of esophagogastric cancer (20.7%) showed complete remission and 32 cases (55.2%) showed partial remission, while 7 cases of distal gastric cancer (5.6%) showed complete remission and 54 cases (43.2%) showed partial remission. Pathologic complete remission was higher for esophagogastric cancer than for distal gastric cancer (20.7% vs 3.2%, p < .05). Differences were found between the NCT and control groups in terms of 1-year, 3-year, and 5-year overall and disease-free survival.

Conclusion:

The PLF regimen showed good tolerability and a high response rate, especially for esophagogastric cancer. This regimen reduced the tumor size, lowered the tumor stage, and improved the R0 resection rate and survival rate.

Comparative Effectiveness of Neoadjuvant Treatments for Resectable Gastroesophageal Cancer: A Network Meta-Analysis

Background: Several neoadjuvant treatments are available for patients with resectable gastroesophageal cancer. We did a Bayesian network meta-analysis (NMA) to compare available treatments, summarizing the direct and indirect evidence. Method: We searched relevant databases for randomized controlled trials of neoadjuvant treatments for resectable gastroesophageal cancer which compared two or more of the following treatments: surgery alone, perioperative docetaxel, oxaliplatin, leucovorin, and fluorouracil (FLOT), and neoadjuvant treatments listed in National Comprehensive Cancer Network guideline. Then we performed a NMA to summarize the direct and indirect evidence to estimate the relative efficacy for outcomes including overall survival (OS), progression-free survival and R0 resection rate. We calculated odds ratio (OR) and hazard ratio (HR) with 95% credible intervals (CrI) for dichotomous data and time-to-event data, respectively. We also calculated the surface under the cumulative ranking curve (SUCRA) value of each intervention to obtain a hierarchy of treatments. Result: Eight eligible trials (2434 patients) were included in our NMA. The treatment with the highest probability of benefit on OS as compared with surgery alone was perioperative FLOT [HR = 0.58 with 95% CrI: (0.43, 0.78), SUCRA = 93%], followed by preoperative radiotherapy, paclitaxel, and carboplatin (RT/PC) [HR = 0.68 with 95% CrI: (0.53, 0.87), SUCRA = 72%], perioperative cisplatin with fluorouracil (CF) [HR = 0.70 with 95% CrI: (0.51, 0.95), SUCRA = 68%], and perioperative epirubicin, cisplatin, and fluorouracil or capecitabine (ECF/ECX) [HR = 0.75 with 95% CrI: (0.60, 0.94), SUCRA = 56%]. Conclusion: Compared with surgery alone, perioperative CF, perioperative ECF/ECX, perioperative FLOT, and preoperative RT/PC significantly improved survival. Perioperative FLOT is likely to be the most effective neoadjuvant treatment for the disease. Further clinical studies are needed and justified.

Inhibitory effects of isocryptotanshinone on gastric cancer

Gastric cancer (GC) is one of the most common digestive malignancies globally, and the prognosis of patients with advanced tumors remains poor. Isocryptotanshinone (ICTS), isolated from Salvia miltiorrhiza, was found to inhibit the proliferation of lung and breast cancer cells. However, whether ICTS has anticancer activities against GC is unknown. In the present study, we reported that the proliferation of GC cells was inhibited by ICTS in a dose- and time-dependent manner. After treatment with ICTS, GC cells were arrested in the G1/G0 phase of cell cycle and the apoptotic cells were induced in a dose-dependent manner. Additionally, ICTS suppressed the expression of cell cycle- and apoptosis-associated proteins (e.g., Cyclin D1, phosphorylated Rb, E2F1, Mcl-1, Bcl-2, and Survivin). ICTS inhibited the phosphorylation of STAT3 in a dose-dependent manner. Down-regulated STAT3 attenuated the expression of Cyclin D1, p-Rb, and Survivin, which remarkably increased the sensitivity of ICTS in GC cells; overexpression of STAT3 restored the cell growth and proliferation and the protein expression suppressed by ICTS. ICTS also suppressed the xenograft tumor growth in BALB/c nude mice. Together, these data indicate that ICTS inhibits GC proliferation by inducing G1/G0 cell cycle arrest and apoptosis via inhibiting the STAT3 signaling pathway.

LDH-Apromotes epithelial-mesenchymal transition by upregulating ZEB2 in intestinal-type gastric cancer

Introduction

Epithelial-mesenchymal transition (EMT) is regarded as a crucial process of invasion and metastasis, which contribute greatly to cancer-related relapse and death. Based on research results that hypoxia can trigger gastric cancer EMT and decreasing lactate production can selectively kill hypoxic cancer cells, we infer that lactate dehydrogenase A (LDH-A) transforming pyruvate into lactate is at least in part responsible for poor prognosis of gastric cancer.

Materials and methods

We used siRNA to knock down LDH-A in intestinal-type gastric cancer (ITGC) cell lines SGC7901 and BGC823. Western blot and RT-PCR were applied to detect mRNA and protein expression of EMT-related genes, respectively. Transwell invasion assay and migration assay were applied to study invasive and migratory abilities, respectively. Survival analysis was used to evaluate prognostic values.

Results and conclusion

The results of in vitro experiment demonstrated that LDH-A facilitates ITGC cells’ invasion and migration by upregulating ZEB2. The positive correlation between LDH-A and ZEB2 was verified in 371 ITGC specimens. Survival analysis indicated that co-expression of LDH-A/ZEB2 had synergetic power to predict overall survival. Thus, we conclude that the close relationship between LDH-A and ZEB2 may offer a potential therapeutic strategy for ITGC.

A systematic review and network meta-analysis protocol of neoadjuvant treatments for patients with gastric cancer

BACKGROUND

National Comprehensive Cancer Network (NCCN) guidelines recommend surgery, chemotherapy, and radiation therapy for gastric cancer patients. Neoadjuvant treatments as the administration of therapeutic agents before a main treatment gained in more and more attention. However, the role of neoadjuvant treatments is still controversial. The main aim of this systematic review and network meta-analysis is to assess the relative efficacy of different neoadjuvant treatment regimens for gastric cancer using network meta-analysis method.

METHODS

We will search 5 electronic databases to identify randomized controlled trials (RCTs) and non-RCTs compared the efficacy differences of surgery alone (S), preoperative chemotherapy follow by surgery (CTS), preoperative radiotherapy follow by surgery (RTS), and preoperative chemoradiotherapy follow by surgery (CRTS) for patients with gastric cancer. The risk of bias tool from the Cochrane Handbook version 5.1.0 will be used to assess the risk of bias of RCTs, and the risk of bias in nonrandomized studies of interventions (ROBINS-I) for non-RCTs. Data will be analyzed using R-3.4.1 software.

RESULTS AND CONCLUSION

The results of present network meta-analysis will estimate the relative efficacy among all interventions and rank the interventions even if head-to-head comparisons are lacking and will provide more evidence for clinicians, researchers, and patients in the management of gastric cancer.Protocol registration number: CRD42017074956.

Neoadjuvant chemotherapy in advanced gastric and esophago-gastric cancer. Meta-analysis of randomized trials

INTRODUCTION

Even in after curative surgery and adequate linfoadenectomy the survival of advanced gastric cancer (AGC) remains poor. At present some data have been published on the effects of NACT and perioperative chemotherapy on AGC and Esophago-gastric cancer (EGC) but not definitive ones. The present meta-analysis aims to evaluate the effects of neoadjuvant chemotherapy (NACT) on the AGC and EGC.

MATERIAL AND METHODS

A systematic review with meta-analysis of randomized controlled trials (RCTs) of NACT + surgery vs. Surgery in patients with AGC and EGC was performed.

RESULTS

15 RCTs have been included (2001 patients: 977 into NACT + surgery arm and 1024 into control arm). NACT + Surgery reduces the overall mortality at 1, 3 and 5-year in cumulative analysis (RR = 0.78; 0.81; 0.88 respectively), at 1, 2, 3 and 5-years in EGC (RR = 0.79; 0.83; 0.84; 0.91 respectively) and at 3 and 5-years in AGC (RR = 0.74; 0.82 respectively). Morbidity and perioperative mortality rate are not influenced by NACT. Recurrence rate is reduced by NACT + surgery in EGC (RR = 0.80).

CONCLUSIONS

NACT reduces the mortality in gastric and esophago-gastric cancer. Morbidity and perioperative mortality are not influenced by NACT. The overall recurrence rate is reduced by NACT in esophago-gastric cancer.

Effect of neoadjuvant chemotherapy in patients with gastric cancer: a PRISMA-compliant systematic review and meta-analysis

BACKGROUND

Neoadjuvant chemotherapy (NAC) is extensively used in the treatment of patients with gastric cancer (GC), particularly in high risk, advanced gastric cancer. Previous trials testing the efficacy of NAC have reported inconsistent results.

METHODS

This study compares the combined use of NAC and surgery with surgery alone for GC by using a meta-analytic approach. We performed an electronic search of PubMed, EmBase, and the Cochrane Library to identify randomized controlled trials (RCTs) on NAC published before Oct 2015. The primary outcome of the studies was data on survival rates for patients with GC. The summary results were pooled using the random-effects model. We included 12 prospective RCTs reporting data on 1538 GC patients.

RESULTS

Patients who received NAC were associated with significant improvement of OS (P = 0.001) and PFS (P < 0.001). Furthermore, NAC therapy significantly increased the incidence of 1-year survival rate (SR) (P = 0.020), 3-year SR (P = 0.011), and 4-year SR (P = 0.001). Similarly, NAC therapy was associated with a lower incidence of 1-year (P < 0.001), 2-year (P < 0.001), 3-year (P < 0.001), 4-year (P = 0.001), and 5-year recurrence rate (P = 0.002). Conversely, patients who received NAC also experienced a significantly increased risk of lymphocytopenia (P = 0.003), and hemoglobinopathy (P = 0.021).

CONCLUSIONS

The findings of this study suggested that NAC is associated with significant improvement in the outcomes of survival and disease progression for GC patients while also increasing some toxicity.

Preoperative tumor restaging and resectability assessment of gastric cancers after chemotherapy: diagnostic accuracy of MDCT using new staging criteria

PURPOSE

To evaluate the diagnostic performance of preoperative MDCT for tumor restaging and determination of resectability in gastric cancers after chemotherapy using new staging criteria.

METHODS

This retrospective study was approved by our institutional review board and the requirement for informed consent was waived. Thirty-seven patients with initially unresectable gastric cancers who had received chemotherapy followed by surgery were included. Two independent radiologists reviewed preoperative MDCT images to determine the TNM staging and rate the overall likelihood of resectability using a 5-point scale (5: definitely unresectable, 1: definitely resectable). New post-chemotherapy MDCT criteria do not use non-enhancing perigastric infiltrations, non-enhancing lymph nodes (LNs), and subtle remaining infiltrations after marked decrease in the size of distant metastases for T, N, and M upstaging, respectively. Discrepancies in TNM staging were resolved by a third reviewer. The diagnostic performances of MDCT were assessed using pathologic results or operation records as reference standards.

RESULTS

For predicting resectability, the areas under the ROC curve were 0.885 and 0.882 (95% CIs 0.737-0.966 and 0.733-0.964) in reviewers 1 and 2, respectively, with substantial inter-reader agreement (weighted κ = 0.689). Sensitivities and specificities of MDCT for tumor restaging on a consensus review were 80.0% (4/5) and 100% (29/29) for T4b, 35.3% (6/17) and 81.3% (13/16) for N-positive, and 63.6% (7/11) and 100% (26/26) for M1, respectively.

CONCLUSIONS

For gastric cancers after chemotherapy, new MDCT criteria demonstrated high specificities for T4b and M-staging and good performances to predict resectability before conversion surgery.

Perioperative chemotherapy for resectable gastric cancer - what is the evidence?

The UK MAGIC trial published in 2006 was the first RCT to identify improved long-term survival rates using preoperative chemotherapy for resectable gastric or gastroesophageal cancer. Overnight, the treatment regimen impacted European guidelines. However, the majority of patients underwent limited lymph node dissection, and analyses of the rates of curative resection, downsizing and downstaging were not by intention to treat, rightfully raising concerns about their validity. For the subset of true gastric cancers, meta-analyses may even question the claims of improved long-term survival rates by present-day regimens. A rhetorical question can be posed as to whether downstaging and improved survival rates by preoperative (radio)-chemotherapy for cancers of the distal esophagus or gastric cardia, has confounded our conclusions on the (lack of) effect of present-day regimens of perioperative chemotherapy for true gastric cancers, let alone in a situation with proper lymph node dissection. At present, a plea can be made to move one step back and revert to an RCT with a surgery alone arm. Inclusion criteria and analyses of future RCTs must stratify on tumor location and the Lauren type and embrace the newly developed scheme of sub-classification of gastric cancers based on extensive molecular profiling as reported in the seminal Cancer Genome Atlas Study.

Lymphoepithelioma-like gastric carcinoma: clinicopathological characteristics and infection status

BACKGROUND

Lymphoepithelioma-like gastric carcinoma (LLGC) is a rare subtype of gastric carcinoma (GC) characterized by prominent lymphocytic infiltration. LLGC may be associated with latent Epstein-Barr virus (EBV) infection or microsatellite instability (MSI). This study aims to assess the clinicopathological characteristics, EBV infection, and MSI status in LLGC.

METHODS

A retrospective analysis of GC patients submitted to potentially curative resection between 2009 and 2014 was performed. The LLGC subtype specimens were examined for EBV by in situ hybridization and MSI by immunohistochemical analysis. The LLGC profile was analyzed accordingly to clinicopathological parameters.

RESULTS

From 255 patients, seven were identified on the pathological report as LLGC. Six cases were EBV-positive and one had MSI, showing loss of MLH1 and PMS2 expression. LLGC was more frequently seen in men, and the mean age was 69 years. When compared to non-LLGC, LLGC cases were larger (∼5.8 cm) poorly differentiated tumors and had lower incidence of lymph node metastasis (P = 0.045). Mean number of lymph nodes dissected in the LLGC group was 39.5, and only one patient had a single positive lymph node. In addition, two patients presented associated lesions. LLGC was not associated with HER-2, chromogranin and synaptophysin positivity or Helicobacter pylori infection.

CONCLUSIONS

Distinct pathological aspects and clinical behavior of LLGC reinforce the need for proper recognition of this histological subtype to choose better therapeutic approaches.

Detection of digestive malignancies and post-gastrectomy complications via gastrointestinal fluid examination

To date, gastric carcinoma (GC) is one of the common and fatal digestive malignancies worldwide. The prognosis of GC is not always satisfactory because of late diagnosis. Scholars are keen on discovering novel accurate and economical biomarkers in body liquids for GC screening to detect and evaluate the lesion before the results of imaging techniques are obtained. While traditional serum assays have limited sensitivity and specificity, gastrointestinal juice may provide relevant specific biomarkers because of its close contact with the tumor. Herein, the current progress in the relationship between gastrointestinal fluid analyses and GC is systematically and comprehensively reviewed. The detection of gastric juice pH, fluorescence spectrum, cytology, Helicobacter pylori-associated markers, nitrosamines, conventional tumor markers, amino acids, proteomics, microRNAs, long noncoding RNAs, protein-coding genes, vitamin C, etc., and combination tests of different category markers could provide important diagnostic and prognostic clues for gastrointestinal diseases. Particularly, early GC may be efficiently screened using gastric juice. Gastrointestinal fluid examination could also predict the adverse effects of postgastrectomy, such as pancreatic leakage, fistula, and abscess. Gastric fluid markers should be further studied to reveal the early predicators of malignancy and complications. The methods for obtaining the samples of gastrointestinal juice with minimum incision should also be comprehensively investigated.

Updated evidence on adjuvant treatments for gastric cancer

Gastric cancer is one of the main causes of cancer-related deaths worldwide. Even when diagnosed as a localized disease and resected with the intent to cure, recurrences frequently arise due to undetected or invisible micrometastases. Importantly, several proposed multimodal strategies to eliminate micrometastases have met some clinical success. However, while pivotal Phase III clinical trials comparing adjuvant therapies with surgery alone have confirmed the overall benefit of adjunctive treatments in patients with locally advanced gastric cancer, further improvement in postoperative outcomes is required, particularly in stage III disease. This review presents the current status of multimodal treatment strategies, with a particular focus on unresolved issues, based on updated literature searches and analysis of clinical trial databases.

Recent insights in the therapeutic management of patients with gastric cancer

Gastric cancer remains frequent and one of the most lethal malignancies worldwide. In this article, we aimed to comprehensively review recent insights in the therapeutic management of gastric cancer, with focus on the surgical and perioperative management of resectable forms, and the latest advances regarding advanced diseases. Surgical improvements comprise the use of laparoscopic surgery including staging laparoscopy, a better definition of nodal dissection, and the development of hyperthermic intraperitoneal chemotherapy. The best individualized perioperative management should be assessed before curative-intent surgery for all patients and can consists in perioperative chemotherapy, adjuvant chemo-radiation therapy or adjuvant chemotherapy alone. The optimal timing and sequence of chemotherapy and radiation therapy with respect to surgery should be further explored. Patients with advanced gastric cancer have a poor prognosis. Nevertheless, they can benefit from doublet or triplet chemotherapy combination, including trastuzumab in HER2-positive patients. Upon progression, second-line therapy can be considered in patients with good performance status. Although anti-HER2 (trastuzumab) and anti-VEGFR (ramucirumab) may yield survival benefit, anti-EGFR and anti-HGFR therapies have failed to improve outcomes. Nevertheless, combination regimens containing cytotoxic drugs and targeted therapies should be further evaluated; keeping in mind that gastric cancer biology is different between Asia and the Western countries.

Chances, risks and limitations of neoadjuvant therapy in surgical oncology

Over the last decades, neoadjuvant treatment has been established as a standard of care for a variety of tumor types in visceral oncology. Neoadjuvant treatment is recommended in locally advanced esophageal and gastric cancer as well as in rectal cancer. In borderline resectable pancreatic cancer, neoadjuvant therapy is an emerging treatment concept, whereas in resectable colorectal liver metastases, neoadjuvant treatment is often used, although the evidence for improvement of survival outcomes is rather weak. What makes neoadjuvant treatment attractive from a surgical oncology viewpoint is its ability to shrink tumors to a smaller size and to increase the chances for complete resection with clear surgical margins, which is a prerequisite for cure. Studies suggest that local tumor control is increased in some visceral tumor types, especially with neoadjuvant chemoradiotherapy. In some other studies, a better control of systemic disease has contributed to significantly improved survival rates. Additionally, delaying surgery offers the chance to bring the patient into a better general condition for major surgery, but it also confers the risk of progression. Although it is a relatively rare event, cancers may progress locally during neoadjuvant treatment or distant metastases may occur, jeopardizing a curative surgical treatment approach. Although this is seen as risk of neoadjuvant treatment, it can also be seen as a chance to select only those patients for surgery who have a better control of systemic disease. Some studies showed increased perioperative morbidity in patients who underwent neoadjuvant treatment, which is another potential disadvantage. Optimal multidisciplinary teamwork is key to controlling that risk. Meanwhile, the neoadjuvant treatment period is also used as a "window of opportunity" for studying the activity of novel drugs and for investigating predictive and prognostic biomarkers of chemoradiotherapy and radiochemotherapy. Although the benefits of neoadjuvant treatment have been clearly established, the risk of overtreatment of cancers with an unfavorable prognosis remains an issue. All indications for neoadjuvant treatment are based on clinical staging. Even if staging is done meticulously, making use of all recommended diagnostic modalities, the risk of overstaging and understaging remains considerable and may lead to false indications for neoadjuvant treatment. Finally, despite all developments and emerging concepts in medical oncology, many cancers remain resistant to the currently available drugs and radiation. This may in part be due to specific molecular resistance mechanisms that are marginally understood thus far. Neoadjuvant treatment has been one of the major advances in multidisciplinary oncology in the last decades, requiring a dedicated treatment team and an optimal infrastructure for complex oncology care. This article discusses the goals and novel directions as well as limitations in neoadjuvant treatment of visceral cancers.

Which is better for gastric cancer patients, perioperative or adjuvant chemotherapy: a meta-analysis

BACKGROUND

The preferred chemotherapy method for gastric cancer continues to be matter of debate. We performed a meta-analysis to comparing prognosis and safety between perioperative chemotherapy and adjuvant chemotherapy to identify the better chemotherapy option for gastric cancer.

METHODS

We searched the PubMed, EMBASE, Cochrane Library, and Ovid databases for eligible studies until February 2016. The main endpoints were prognostic value (hazard ratio [HR] for overall survival [OS] and 1-, 2-, 3-, and 5-year survival rate), response rate of chemotherapy, radical resection rate, post-operative complication rate, and adverse effects of chemotherapy.

RESULTS

Five randomized controlled trials and six clinical controlled trials involving 1,240 patients were eligible for analysis. Compared with the adjuvant chemotherapy group, the perioperative chemotherapy group had significantly better prognosis (HR, 0.74; 95 % CI, 0.61 to 0.89; P < 0.01). The difference between the two groups remained significant in the studies that used combination chemotherapy as the neoadjuvant chemotherapy regimen (HR, 0.59; 95 % CI, 0.46 to 0.76; P < 0.01) but were not significant in the studies that used fluoropyrimidine monotherapy (HR, 0.93; 95 % CI, 0.56 to 1.55; P = 0.84). Furthermore, the two groups showed no significant differences in the post-operative complication rates (relative risk, 0.98; 95 % CI, 0.63 to 1.51; P = 0.91) or adverse effects of chemotherapy (P > 0.05 for all adverse effects).

CONCLUSION

Perioperative chemotherapy showed improved survival compared to adjuvant chemotherapy for gastric cancer. In addition, combination chemotherapy resulted in better survival compared to monotherapy in the neoadjuvant chemotherapy regimens.

Comparison of neoadjuvant versus a surgery first approach for gastric and esophagogastric cancer

Gastric cancer remains a significant worldwide health concern. While surgery is required for cure, all but the earliest of cancers will require multimodality therapy. Chemotherapy and chemoradiation in the neoadjuvant and adjuvant settings have shown to improve overall survival, but the sequencing of treatment is controversial. As healthcare expenses surge, it is increasingly important to impart value to these treatments. This review will look at the intersection of effective treatment and costs for gastric cancer. J. Surg. Oncol. 2016;114:296-303. © 2016 Wiley Periodicals, Inc.