1
|
Bhandare MS, Gundavda KK, Yelamanchi R, Chopde A, Batra S, Kolhe M, Ramaswamy A, Ostwal V, Deodhar K, Chaudhari V, Shrikhande SV. Impact of pCR after neoadjuvant chemotherapy and radical D2 dissection in locally advanced gastric cancers: Analysis of 1001 cases. Eur J Surg Oncol 2024; 50:108343. [PMID: 38640606 DOI: 10.1016/j.ejso.2024.108343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 04/09/2024] [Accepted: 04/12/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND Advances in perioperative chemotherapy have improved outcomes in patients with gastric cancers (GC). This strategy leads to tumour downstaging and may result in a pathologic complete response (pCR). The study aimed to evaluate the predictors of pCR and determine the impact of pCR on long-term survival. METHODS At the Department of Gastrointestinal and HPB Oncology at the Tata Memorial Centre, Mumbai, 1001 consecutive patients with locally advanced GCs undergoing radical resection following neoadjuvant chemotherapy from January 2005 to June 2022 were included. RESULTS At a median follow-up of 61 months, the median OS was 53 months with a 5-year OS of 46.8 %. Ninety-five patients (9.49 %) realized pCR. Non-signet and well-differentiated histology were associated with pCR. pCR was significantly associated with improved OS, 5-year OS 79.2 % vs 43.2 % (HR 0.30, p < 0.001). On multivariable analysis, the realization of pCR and completion of adjuvant chemotherapy had superior OS. Whereas, signet-ring histology, linitis-like tumours, and high lymph node ratio had adverse outcomes. CONCLUSION Tumour grade and signet-ring histology predict achievement of pCR in locally advanced GCs after neoadjuvant chemotherapy. Patients with pCR have significantly improved survival. Future neoadjuvant strategies should focus on enhancing pCR rates to improve overall outcomes.
Collapse
Affiliation(s)
- Manish S Bhandare
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
| | - Kaival K Gundavda
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
| | - Raghav Yelamanchi
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
| | - Amit Chopde
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
| | - Swati Batra
- Department of Surgical Oncology, Armed Forces Medical Services (Army Hospital, Research and Referral), Delhi, India.
| | - Manjushree Kolhe
- Department of Statistics, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
| | - Anant Ramaswamy
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
| | - Vikas Ostwal
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
| | - Kedar Deodhar
- Department of Pathology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
| | - Vikram Chaudhari
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
| | - Shailesh V Shrikhande
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
| |
Collapse
|
2
|
Shannon AH, Sarna A, Bressler L, Monsour C, Palettas M, Huang E, D'Souza DM, Kneuertz PJ, Ejaz A, Pawlik TM, Santry H, Cloyd JM. Quality of Life and Real-time Patient Experience During Neoadjuvant Therapy: A Prospective Cohort Study. Ann Surg 2024; 279:850-856. [PMID: 37641957 DOI: 10.1097/sla.0000000000006090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
OBJECTIVE To use a customized smartphone application to prospectively measure QOL and the real-time patient experience during neoadjuvant therapy (NT). BACKGROUND NT is increasingly used for patients with localized gastrointestinal (GI) cancers. There is little data assessing patient experience and quality of life (QOL) during NT for GI cancers. METHODS Patients with GI cancers receiving NT were instructed on using a customized smartphone application through which the Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire, a validated measure of health-related QOL, was administered at baseline, every 30 days, and at the completion of NT. Participants also tracked their moods and symptoms and used free-text journaling functionalities in the application. Mean overall and subsection health-related QOL scores were calculated during NT. RESULTS Among 104 enrolled patients, the mean age was 60.5 ± 11.5 years and 55% were males. Common cancer diagnoses were colorectal (40%), pancreatic (37%), and esophageal (15%). Mean overall FACT-G scores did not change during NT ( P = 0.987). While functional well-being scores were consistently the lowest and social well-being scores the highest, FACT subscores similarly did not change during NT (all P > 0.01). The most common symptoms reported during NT were fatigue, insomnia, and anxiety (39.3%, 34.5%, and 28.3% of patient entries, respectively). Qualitative analysis of free-text journaling entries identified anxiety, fear, and frustration as the most common themes, but also the importance of social support systems and confidence in health care providers. CONCLUSIONS While patient symptom burden remains high, results of this prospective cohort study suggest QOL is maintained during NT for localized GI cancers.
Collapse
Affiliation(s)
- Alexander H Shannon
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Giampieri R, Baleani MG, Bittoni A, Rastelli F, Catalano V, Del Prete M, Chiorrini S, Pinterpe G, Graziano F, Giorgi FC, Bisonni R, Silva R, Alessandroni P, Mencarini L, Berardi R. Impact of Signet-Ring Cell Histology in the Management of Patients with Non-Metastatic Gastric Cancer: Results from a Retrospective Multicenter Analysis Comparing FLOT Perioperative Chemotherapy vs. Surgery Followed by Adjuvant Chemotherapy. Cancers (Basel) 2023; 15:3342. [PMID: 37444451 DOI: 10.3390/cancers15133342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/14/2023] [Accepted: 06/23/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND FLOT perioperative chemotherapy represents the standard of care in non-metastatic gastric cancer patients. Signet-ring cell positivity is associated with a worse prognosis in patients with gastric cancer treated with chemotherapy. Comparison between FLOT perioperative chemotherapy vs. surgery followed by adjuvant chemotherapy based on signet-ring cell positivity is lacking. The aim of the analysis was to compare perioperative FLOT with adjuvant chemotherapy in gastric cancer patients stratified by signet-ring cell positivity. METHODS We conducted a retrospective multicenter analysis based on disease-free survival (DFS) and overall survival (OS) in patients with gastric cancer who received perioperative chemotherapy with a FLOT regimen and compared their survival with a historical cohort of patients treated with adjuvant chemotherapy, matched by cT and cN stage and by tumor histological features. RESULTS Seventy-six patients were enrolled and 24 (32%) were signet-ring cell positive. At a median follow-up time of 39 months, the median DFS was 26.3 months and the median OS was 37.3 months. Signet-ring cell positivity was associated with a shorter OS (median OS: 20.4 vs. 46.9 months, HR: 3.30, 95%CI: 1.56-6.99, p = 0.0018) and DFS (mDFS: 15.2 vs. 38.6 months, HR: 3.18, 95%CI: 1.55-6.54, p = 0.0016). This was confirmed by multivariate analysis for DFS (Exp(B): 2.55) and OS (Exp(B): 2.68). After propensity score matching, statistically significant shorter DFS (HR: 3.30, 95%CI: 1.50-7.35, p = 0.003) and OS (HR: 5.25, 95%CI: 2.18-12-68, p = 0.0002) were observed for patients with signet-ring cell positivity who received perioperative treatment vs. those who received surgery followed by adjuvant chemotherapy. CONCLUSIONS Signet-ring positivity was associated with shorter DFS and OS in patients who received perioperative treatment with FLOT compared with surgery followed by adjuvant therapy. These data suggest that for patients with signet-ring cell histology, FLOT perioperative treatment might not always be the best choice of treatment, and further research should be focused on this group of patients.
Collapse
Affiliation(s)
- Riccardo Giampieri
- Medical Oncology Unit, Dipartimento Scienze Cliniche e Molecolari, Università Politecnica delle Marche and Azienda Ospedaliero-Universitaria Ospedali Riuniti delle Marche, 60126 Ancona, Italy
| | | | - Alessandro Bittoni
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", 47014 Meldola, Italy
| | - Francesca Rastelli
- Department of Oncology, Ospedale "C.e G. Mazzoni" Ascoli Piceno, 63100 Ascoli Piceno, Italy
| | - Vincenzo Catalano
- Department of Oncology, Ospedale Santa Maria della Misericordia, AV1, 61029 Urbino, Italy
| | - Michela Del Prete
- Department of Oncology, Ospedale Augusto Murri di Fermo, 63900 Fermo, Italy
| | - Silvia Chiorrini
- Department of Oncology, Ospedale E. Profili, 60044 Fabriano, Italy
| | - Giada Pinterpe
- Medical Oncology Unit, Dipartimento Scienze Cliniche e Molecolari, Università Politecnica delle Marche and Azienda Ospedaliero-Universitaria Ospedali Riuniti delle Marche, 60126 Ancona, Italy
| | - Francesco Graziano
- Department of Oncology, Azienda Ospedaliera Marche Nord, AV1, 61121 Pesaro, Italy
| | - Francesca Chiara Giorgi
- Department of Oncology, Ospedale Madonna del Soccorso, 63074 San Benedetto del Tronto, Italy
| | - Renato Bisonni
- Department of Oncology, Ospedale Augusto Murri di Fermo, 63900 Fermo, Italy
| | - Rosarita Silva
- Department of Oncology, Ospedale E. Profili, 60044 Fabriano, Italy
| | - Paolo Alessandroni
- Department of Oncology, Azienda Ospedaliera Marche Nord, AV1, 61121 Pesaro, Italy
| | - Lara Mencarini
- Medical Oncology Unit, Dipartimento Scienze Cliniche e Molecolari, Università Politecnica delle Marche and Azienda Ospedaliero-Universitaria Ospedali Riuniti delle Marche, 60126 Ancona, Italy
| | - Rossana Berardi
- Medical Oncology Unit, Dipartimento Scienze Cliniche e Molecolari, Università Politecnica delle Marche and Azienda Ospedaliero-Universitaria Ospedali Riuniti delle Marche, 60126 Ancona, Italy
| |
Collapse
|
4
|
Patil P, Clements HA, Ramkumar PG, Walsh S, Petty R. Total neoadjuvant chemotherapy: a silver lining during the COVID pandemic for a patient with locally advanced diffuse distal gastric adenocarcinoma. Ann R Coll Surg Engl 2022; 104:e197-e201. [PMID: 34846214 PMCID: PMC9246550 DOI: 10.1308/rcsann.2021.0235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Perioperative oncological therapies resulting in pathological complete response (pCR) in diffuse-type distal gastric adenocarcinoma are extremely rare. We report a case of locally advanced (cT3 N2 M0) diffuse-type distal gastric adenocarcinoma treated with 'total neoadjuvant' FLOT (eight cycles), due to the COVID-19 pandemic, and laparoscopic radical subtotal gastrectomy with D2 lymphadenectomy. The patient demonstrated a progressive radiological response on positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro-d-glucose integrated with computed tomography (18F-FDG PET-CT) and pCR in the resected specimen (ypT0 N0). As far as we are aware, this is the first case of pCR in locally advanced T3 N2 diffuse distal gastric cancer to be reported in the literature. It introduces a novel approach of total neoadjuvant chemotherapy with 18F-FDG PET-CT to assess response, combined with radical minimally invasive surgical management to provide optimal care for patients with gastric cancer.
Collapse
|
5
|
Davern M, O' Brien RM, McGrath J, Donlon NE, Melo AM, Buckley CE, Sheppard AD, Reynolds JV, Lynam-Lennon N, Maher SG, Lysaght J. PD-1 blockade enhances chemotherapy toxicity in oesophageal adenocarcinoma. Sci Rep 2022; 12:3259. [PMID: 35228614 DOI: 10.1038/s41598-022-07228-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/01/2022] [Indexed: 12/17/2022] Open
Abstract
Chemotherapy upregulates immune checkpoint (IC) expression on the surface of tumour cells and IC-intrinsic signalling confers a survival advantage against chemotherapy in several cancer-types including oesophageal adenocarcinoma (OAC). However, the signalling pathways mediating chemotherapy-induced IC upregulation and the mechanisms employed by ICs to protect OAC cells against chemotherapy remain unknown. Longitudinal profiling revealed that FLOT-induced IC upregulation on OE33 OAC cells was sustained for up to 3 weeks post-treatment, returning to baseline upon complete tumour cell recovery. Pro-survival MEK signalling mediated FLOT-induced upregulation of PD-L1, TIM-3, LAG-3 and A2aR on OAC cells promoting a more immune-resistant phenotype. Single agent PD-1, PD-L1 and A2aR blockade decreased OAC cell viability, proliferation and mediated apoptosis. Mechanistic insights demonstrated that blockade of the PD-1 axis decreased stem-like marker ALDH and expression of DNA repair genes. Importantly, combining single agent PD-1, PD-L1 and A2aR blockade with FLOT enhanced cytotoxicity in OAC cells. These findings reveal novel mechanistic insights into the immune-independent functions of IC-intrinsic signalling in OAC cells with important clinical implications for boosting the efficacy of the first-line FLOT chemotherapy regimen in OAC in combination with ICB, to not only boost anti-tumour immunity but also to suppress IC-mediated promotion of key hallmarks of cancer that drive tumour progression.
Collapse
|
6
|
Puhr HC, Preusser M, Ilhan-Mutlu A. Immunotherapy for Esophageal Cancers: What Is Practice Changing in 2021? Cancers (Basel) 2021; 13:4632. [PMID: 34572859 PMCID: PMC8472767 DOI: 10.3390/cancers13184632] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 09/10/2021] [Accepted: 09/13/2021] [Indexed: 12/15/2022] Open
Abstract
The prognosis of advanced esophageal cancer is dismal, and treatment options are limited. Since the first promising data on second-line treatment with checkpoint inhibitors in esophageal cancer patients were published, immunotherapy was surmised to change the face of modern cancer treatment. Recently, several studies have found this to be true, as the checkpoint inhibitors nivolumab and pembrolizumab have achieved revolutionary response rates in advanced as well as resectable settings in esophageal cancer patients. Although the current results of large clinical trials promise high efficacy with tolerable toxicity, desirable survival rates, and sustained quality of life, some concerns remain. This review aims to summarize the novel clinical data on immunotherapeutic agents for esophageal cancer and provide a critical view of potential restrictions for the implementation of these therapies for unselected patient populations.
Collapse
Affiliation(s)
- Hannah Christina Puhr
- Division of Oncology, Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria; (H.C.P.); (M.P.)
- Comprehensive Cancer Center Vienna, 1090 Vienna, Austria
| | - Matthias Preusser
- Division of Oncology, Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria; (H.C.P.); (M.P.)
- Comprehensive Cancer Center Vienna, 1090 Vienna, Austria
| | - Aysegül Ilhan-Mutlu
- Division of Oncology, Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria; (H.C.P.); (M.P.)
- Comprehensive Cancer Center Vienna, 1090 Vienna, Austria
| |
Collapse
|