Lymphadenectomy in elderly/high risk patients: should it be different?

Lymph Node Dissection of Choice in Older Adult Patients with Gastric Cancer: A Systematic Review and Meta-Analysis

Background: Although the current literature has shown an increasing interest in surgical treatment of gastric cancer (GC) in older adults in recent years, there is still no consensus on proper management in this subgroup of patients. This study was designed with the objective of evaluating the current evidence that compares limited lymph node dissection with extended lymph node dissection in older adult patients (≥65 years) coursing with resectable GC. Methods: A systematic review of PubMed, Cochrane library, and ScienceDirect was performed according to PRISMA guidelines. All studies before 2018 were selected using a systematic review by Mogal et al. Studies were eligible for this meta-analysis if they were randomized controlled trials or non-randomized comparative studies comparing limited lymph node dissection versus extended lymph node dissection in patients with resectable GC taken to gastrectomy. Results: Seventeen studies and a total of 5056 patients were included. There were not any statistically significant differences in OS (HR = 1.04, CI95% = 0.72-1.51), RFS (HR = 0.92, CI95% = 0.62-1.38), or CSS (HR = 1.24, CI95% = 0.74-2.10) between older adult patients taken to limited and extended lymphadenectomy in addition to gastrectomy as the current surgical treatment for GC. Although a higher rate of major complications was observed in the extended lymphadenectomy group, this difference was not statistically significant in incidence between both groups of patients (OR = 1.92, CI95% = 0.75-4.91). Conclusions: Limited lymphadenectomy must be considered as the better recommendation for surgical treatment for GC in older adult patients, considering the oncological outcomes and lower rates of complications compared with more radical lymph node dissections.

The efficacy of adjuvant chemotherapy for older adults with stage II/III gastric cancer: a retrospective cohort study

BACKGROUND

Adjuvant chemotherapy is recommended as the standard treatment for patients with stage II/III resected gastric cancer. However, it is unclear whether older patients also benefit from an adjuvant chemotherapy strategy. This study aimed to investigate the clinical impact of adjuvant chemotherapy in older patients with stage II/III gastric cancer.

METHODS

This retrospective, real-world study analyzed 404 patients with stage II/III gastric cancer visited at our institute between January 2009 and December 2019. The clinical characteristics and outcomes of patients aged 70 years or older who received adjuvant chemotherapy were compared with those who did not receive this type of treatment. Propensity score analysis was performed to mitigate selection bias.

RESULTS

Of the 404 patients analyzed, 179 were aged 70 years or older. Fewer older patients received adjuvant chemotherapy than did younger patients (60.9% vs. 94.7%, respectively; P < 0.001). Among patients aged 70 years or older, those who received adjuvant chemotherapy had improved disease-free survival (DFS) (5-year DFS rate, 53.1% vs. 30.4%; P < 0.001) and overall survival (OS) (5-year OS rate, 68.7% vs. 52.1%; P = 0.002) compared to those who did not receive adjuvant chemotherapy. A similar survival benefit was observed in the propensity-matched cohort. Multivariate analysis showed that more advanced stage was associated with poorer OS. Receipt of adjuvant chemotherapy was independently associated with a decreased hazard of death (hazard ratio (HR), 0.37; 95% confidence intervals (CI), 0.20-0.68; P = 0.002).

CONCLUSIONS

Adjuvant chemotherapy may benefit older stage II/III gastric cancer patients aged ≥ 70 years. Further prospective studies are needed to confirm these findings.

Hepatocyte Growth Factor and Macrophage-stimulating Protein "Hinge" Analogs to Treat Pancreatic Cancer

Pancreatic cancer (PC) ranks twelfth in frequency of diagnosis but is the fourth leading cause of cancer related deaths with a 5 year survival rate of less than 7 percent. This poor prognosis occurs because the early stages of PC are often asymptomatic. Over-expression of several growth factors, most notably vascular endothelial growth factor (VEGF), has been implicated in PC resulting in dysfunctional signal transduction pathways and the facilitation of tumor growth, invasion and metastasis. Hepatocyte growth factor (HGF) acts via the Met receptor and has also received research attention with ongoing efforts to develop treatments to block the Met receptor and its signal transduction pathways. Macrophage-stimulating protein (MSP), and its receptor Ron, is also recognized as important in the etiology of PC but is less well studied. Although the angiotensin II (AngII)/AT1 receptor system is best known for mediating blood pressure and body water/electrolyte balance, it also facilitates tumor vascularization and growth by stimulating the expression of VEGF. A metabolite of AngII, angiotensin IV (AngIV) has sequence homology with the "hinge regions" of HGF and MSP, key structures in the growth factor dimerization processes necessary for Met and Ron receptor activation. We have developed AngIV-based analogs designed to block dimerization of HGF and MSP and thus receptor activation. Norleual has shown promise as tested utilizing PC cell cultures. Results indicate that cell migration, invasion, and pro-survival functions were suppressed by this analog and tumor growth was significantly inhibited in an orthotopic PC mouse model.

Return to Intended Oncologic Treatment (RIOT) in Resected Gastric Cancer Patients

BACKGROUND

Postoperative chemotherapy (CMT) or chemoradiotherapy (CRT) is commonly recommended for gastric cancer (GC) patients in order to improve survival. However, some factors that prevent patients from return to intended oncologic treatment (RIOT) may increase the risk of recurrence and decrease the survival benefits achieved with curative resection. The aim of this study was to determine the frequency and factors associated with inability to RIOT and their impact on survival.

METHODS

This retrospective study included stage II/III GC patients treated with potentially curative gastrectomy. Patients who could return to intended oncologic treatment (RIOT group) and those who could not (inability to RIOT group) were analyzed.

RESULTS

Of the 313 eligible GC patients, 89 (28.4%) and 85 (27.2%) patients receive CRT and CMT, respectively, representing a RIOT rate of 55.6%. The main reason was attributed to general poor performance status (30.2%), followed by surgical postoperative complications (POC) (20.1%). Older age, higher ASA, D1 lymphadenectomy, and major POC were related to inability to RIOT. Older age, neutrophil-lymphocyte ratio (NLR), and major POC were independent risk factors for inability to RIOT. Five-year DFS and OS were worse for the inability to RIOT group than for the RIOT group (p = 0.008 and p = 0.004, respectively). In multivariate analyses, absence of neoadjuvant therapy, total gastrectomy, pT3/T4, pN+, and inability to RIOT were associated with worse DFS. Type of gastrectomy, lymphadenectomy, pN status, Rx resection, and RIOT group were associated with OS.

CONCLUSION

Older age, high NLR, and major POC were risk factors for inability to RIOT. RIOT was an independent predictor of survival.

Clinical significance of neutrophil-to-lymphocyte ratio as a predictor of lymph node metastasis in gastric cancer

Background

Precise staging is indispensable to select the appropriate treatment strategy for gastric cancer (GC); however, the diagnostic accuracy of conventional modalities needs to be improved. This study investigated the clinical significance of the preoperative neutrophil-to-lymphocyte ratio (NLR) for the prediction of pathological lymph node metastasis (pN+) in GC.

Methods

This was a retrospective study of 429 patients with GC who underwent curative gastrectomy. The predictive ability of NLR for pN+ was examined in comparison with that of computed tomography.

Results

The preoperative NLR ranged from 0.6 to 10.8 (median, 2.0), and the optimal cut-off value for predicting pN+ was 1.6 according to the receiver operating characteristic curve with the maximal Youden index. Multivariate analysis identified a NLR ≥ 1.6 (odds ratio (OR) 3.171; 95% confidence interval (CI) 1.448–7.235, p = 0.004) and cN+ (OR 2.426; 95% CI 1.221–4.958, p = 0.011) to be independent factors associated with pN+ in advanced GC (cT2-T4). On the other hand, a NLR ≥ 1.6 was not useful for predicting pN+ in early GC (cT1). In advanced GC, a NLR ≥ 1.6 detected pN+ with a higher sensitivity (84.9%) and negative predictive value (NPV) (63.9%) than conventional modalities (50.0 and 51.7%, respectively). When the subjects were limited to those with advanced GC with cN0, the sensitivity and NPV of a NLR ≥ 1.6 for pN+ increased further (90.7 and 81.0%, respectively).

Conclusion

The preoperative NLR may be a useful complementary diagnostic tool for predicting pN+ in advanced GC because of its higher sensitivity and NPV than conventional modalities.

Optimal treatment for elderly patients with resectable proximal gastric carcinoma: a real world study based on National Cancer Database

Background

High perioperative morbidity, mortality, and uncertain outcome of surgery in octogenarians with proximal gastric carcinoma (PGC) pose a dilemma for both patients and physicians. We aim to evaluate the risks and survival benefits of different strategies treated in this group.

Methods

Octogenarians (≥80 years) with resectable proximal gastric carcinoma who were recommended for surgery were identified from National Cancer Database during 2004–2013.

Results

Patients age ≥ 80 years with PGC were less likely to be recommended or eventually undergo surgery compared to younger patients. Patients with surgery had a significantly better survival than those without surgery (5-year OS: 26% vs. 7%, p < 0.001), especially in early stage patients. However, additional chemotherapy (HR: 0.94, 95% CI: 0.82–1.08, P = 0.36) or radiotherapy (HR: 0.97, 95% CI: 0.84–1.13, P = 0.72) had limited benefits. On multivariate analysis, surgery (HR: 0.66, 95% CI: 0.51–0.86, P = 0.002) was a significant independent prognostic factor, while extensive surgery had no survival benefit (Combined organ resection: HR: 1.88, 95% CI: 1.22–2.91, P = 0.004; number of lymph nodes examined: HR: 0.99, 95% CI: 0.97–1.00, P = 0.10). Surgery performed at academic and research (AR) medical center had the best survival outcome (5-year OS: 30% in AR vs. 18–27% in other programs, P < 0.001) and lowest risk (30-day mortality: 1.5% in AR vs. 3.6–6.6% in other programs, P < 0.001; 90-day mortality: 6.2% in AR vs. 13.6–16.4% in other programs, P < 0.001) compared to other facilities.

Conclusions

Less-invasive approach performed at academic and research medical center might be the optimal treatment for elderly patients aged ≥80 yrs. with early stage resectable PGC.

Is it safe to perform gastrectomy in gastric cancer patients aged 80 or older?: A meta-analysis and systematic review

BACKGROUND

Few studies have focused on octogenarian patients with gastric cancer (GC) who have undergone gastrectomy. This meta-analysis of published studies was performed to assess the safety of treating octogenarian GC patients with surgery.

METHODS

Databases, including PubMed, Embase, Web of Science, and Cochrane Library were searched until January 2019. The incidence of preoperative comorbidities, postoperative complications, and mortality was assessed using odds ratios (ORs) with corresponding 95% confidence intervals (CIs). Further, the hazard ratios (HRs) with 95% CIs were applied for survival outcomes.

RESULTS

A total of 18,179 patients with GC in 21 studies were included. Our results demonstrated that octogenarian patients were associated with a higher burden of comorbidities (OR = 2.79; 95% CI: 2.37, 3.28; P = .00), high incidences of overall postoperative complications (OR = 1.48; 95% CI: 1.22, 1.81; P = .00), medical postoperative complications (OR = 2.58; 95% CI: 1.91, 3.49; P = .00), in-hospital mortality (OR = 3.24; 95% CI: 2.43, 4.31; P = .00) and poor overall survival (HR = 1.96; 95% CI: 1.65, 2.27; P = .00).

CONCLUSIONS

Considering the high burden of comorbidities, high incidences of postoperative complications and mortality, surgery for extremely elderly patients with GC requires deliberation. Individualized treatment is recommended for such patients.

Surgical outcomes of gastrectomy with D1 lymph node dissection performed for patients with unfavorable clinical conditions

BACKGROUND

Gastric cancer (GC) patients with advanced age and/or multiple morbidities have limited expected survival and may not benefit from extended lymph node resection. The aim of this study was to evaluate the surgical outcomes of these GC patients who underwent gastrectomy with D1 dissection.

METHODS

We retrospectively reviewed all GC patients who underwent gastrectomy with curative intent from 2009 to 2017. The decision to perform D1 was based on preoperative multidisciplinary meeting, and/or intraoperative clinical judgment.

RESULTS

Among 460 enrolled patients, 73 (15.9%) underwent D1 lymphadenectomy and 387 (84.1%) D2 lymphadenectomy. Male gender, older age, American Society of Anesthesiologists score (ASA) III/IV, higher neutrophil-to-lymphocyte ratio (NLR) and higher Charlson Comorbidity Index (CCI) were more common in the D1 group. Postoperative major complications were significantly higher in D1 group (24.7% vs 12.4%, p < 0.001) and mostly related to clinical complications. Locoregional recurrence was higher in the D1 group (53.8% vs 39.5%, p = 0.330) however, without statistical significance. No difference was found in disease-free survival (DFS) between D1 and D2 patients with positive lymph nodes (p = 0.192), whereas overall survival was longer in the D2 group (p < 0.001). Multivariate analysis showed a statistically significant impact on survival of age ≥70 years, CCI ≥5, total gastrectomy, D1 lymphadenectomy and advanced stages (III/IV).

CONCLUSIONS

Frail patients had high surgical mortality even when submitted to D1 dissection. DFS was comparable to D2. Extent of lymphadenectomy in high-risk patients should take in account the expectation of a decrease in surgical risk with the possibility of impairment of long-term survival.