Clinicopathological features and surgical safety of gastric cancer in elderly patients

Safety and Feasibility of Gastrectomy in Super Elderly Patients (Aged ≥ 80): A Propensity Score-Matched Analysis

INTRODUCTION

The benefits of gastrectomy in elderly patients with gastric cancer (GC) remain unknown. This study was conducted to evaluate the short- and long-term outcomes of elderly patients with GC (≥ 80 years) who underwent gastrectomy.

METHODS

We enrolled 479 patients (Stages I-IV) who underwent gastrectomy with R0-1 resection. The patients were divided into an elderly group (E group; age ≥ 80 years) (n = 115) and a non-elderly group (NE group; age < 80 years) (n = 364). After propensity score matching (PSM) was performed, the short- and long-term outcomes were compared between the groups.

RESULTS

The rate of postoperative complications (Clavien-Dindo classification ≥ IIIa) in the two groups did not differ significantly (p = 0.657). Before PSM, the five-year overall survival (OS, 35.3% vs. 71.7%, p < 0.001) and disease-specific survival (DSS, 56.8% vs. 81.8%, p < 0.001) in the E group were significantly shorter than that in the NE group, respectively. On the other hand, significant differences between the E and NE groups were not shown in either the five-year OS (35.5% vs. 50.8%, p = 0.0985) or the five-year DSS (56.5% vs. 66.9%, p = 0.274) after PSM.

CONCLUSION

Gastrectomy for elderly patients with GC can be considered safe based on short-term outcomes. In terms of long-term results, elderly patients are not inferior to non-elderly patients if the patients' backgrounds are the same. On the other hand, the long-term outcomes of elderly GC patients who have various comorbidities are not satisfactory, so we should carefully consider the indications for gastrectomy.

Gastric cancer in older adult patients: a retrospective study and literature review

Background

With increasing life expectancy, the incidence of gastric cancer (GC) in older adults is increasing. This study analyzed differences in GC characteristics according to age and sex among patients who underwent surgical treatment for GC.

Methods

A total of 2,983 patients diagnosed with gastric adenocarcinoma who underwent surgical treatment at Seoul National University Bundang Hospital between 2003 and 2017 were classified into three groups: I (<65 years, n=1,680), II (60–74 years, n=919), and III (≥75 years, n=384). We compared the baseline clinical characteristics, pathological characteristics of the tumor, overall and GC-specific survival rates, and associated risk factors between the groups.

Results

Cancer of the distal third of the stomach (p<0.001), with intestinal-type histology (p<0.001), and with p53 overexpression (p=0.004) were more common in groups II and III than in group I, and the proportion of intestinal-type GC increased with age. The cancer type, lymph node metastasis, and cancer stage did not differ significantly. In terms of overall survival, survival decreased with increasing age (p<0.001), but this difference decreased significantly for GC-specific survival. Cox multivariate analyses revealed age, histologic type (diffuse or mixed type), and advanced cancer stage (p=0.002, 0.001, and <0.001, respectively) as risk factors for GC-related mortality.

Conclusion

Age itself was found to be one of the most important prognostic factors for overall and disease-specific survival in elderly GC patients, along with cancer stage.

Prognosis of Elderly Patients with Advanced Gastric Cancer without Serosal Invasion

Introduction

The impact of age on the prognosis of patients with gastric cancer is controversial. This study aimed to investigate the clinicopathologic features and prognosis of elderly advanced gastric cancer patients without serosal invasion compared to their younger counterparts.

Materials and Methods

We retrospectively evaluated 43 elderly patients with advanced gastric cancer without serosal invasion. The clinicopathologic findings were compared between the elderly (age >70 years) and young (age <36 years) patients.

Results

Significantly higher numbers of elderly patients had tumours with differentiated histology, whereas more young patients had tumours with undifferentiated histology (P < 0.01). Curability (risk ratio, 3.122; confidence interval, 1.242-4.779; P < 0.001) was an independent prognostic factor of survival. The 5-year survival rates were not significantly different between the elderly and the young patients according to the absence of serosal invasion (80.0% vs. 77.9%; P = 0.654) and undergoing curative resection (82.0% vs. 78.9%; P = 0.312). Meanwhile, among the elderly patients, those who underwent curative resection had a better survival rate than those with non-curative resection (82.0% vs. 67.8%; P < 0.001).

Conclusion

Elderly patients with advanced gastric cancer without serosal invasion do not have a worse prognosis than their younger counterparts, indicating that age does not impact the prognosis of advanced gastric cancer. The important prognostic factor was whether the patients underwent curative resection.

Is Laparoscopic Gastrectomy More Advantageous for Elderly Patients Than for Young Patients with Resectable Advanced Gastric Cancer?

BACKGROUND

Laparoscopic gastrectomy (LG) is now practiced widely, but it is unclear whether LG is the appropriate approach for elderly patients with resectable advanced gastric cancer. The aim of this study was to examine whether LG is more or less advantageous for elderly patients than for young patients.

METHODS

We collected data on 571 consecutive patients who underwent gastrectomy for pT2-4 gastric cancer between January 2001 and December 2015. After adjustment with one-to-one propensity score matching, short-term and long-term outcomes were compared between the LG and open gastrectomy (OG) groups among young (age < 70 years) and elderly (age ≥ 70 years) patients.

RESULTS

The LG group had a significantly longer operative time (P < 0.001) and less blood loss (P < 0.001) than the OG group among young and elderly patients. There were no significant differences regarding complications. Although disease-specific survival was similar between the LG and OG groups among young and elderly patients, LG was associated with more favorable overall survival than OG only among elderly patients (hazard ratio 0.67; 95% confidence interval 0.35-1.26). Death from respiratory diseases occurred more frequently in the OG group (10.9%) than in the LG group (0%) for elderly patients (P = 0.012).

CONCLUSION

LG for resectable advanced gastric cancer was not inferior to OG in terms of both short-term and long-term outcomes regardless of patient age. In elderly patients, LG may improve overall survival by reducing mortality from respiratory diseases.

Establishment and verification of a nomogram for predicting the risk of lymph node metastasis in early gastric cancer

BACKGROUND

endoscopic submucosal dissection (ESD) has been widely recognized by patients and doctors due to its advantages in early gastric cancer (EGC). The accurate prediction of the risk of lymph node metastasis (LNM) in EGC is important to select suitable treatments with this procedure for patients. Unfortunately, the accuracy of endoscopic ultrasound and computed tomography in the diagnosis of EGC lymph node status is extremely limited. The purpose of the present study was to establish an LNM nomogram risk model of early gastric cancer patients based on clinical data, to guide treatment for clinicians.

METHODS

a retrospective examination of the records of EGC patients undergoing radical gastrectomy from August 2012 to August 2019 in the Gastrointestinal Center of Subei People's Hospital was performed. The clinicopathological data were classified into a training set and validation set according to the time. Univariate and multivariate analyses were performed to identify risk factors related to LNM. A risk model for predicting the occurrence of LNM in EGC was established and validated.

RESULTS

of the 503 EGC patients, 78 (15.5 %) had lymph node metastasis. Logistic stepwise regression analysis showed that the predictive factors included sex, tumor location, tumor diameter, differentiation, ulcer and lymphatic vascular invasion. The discrimination of the LNM prediction model was satisfactory with an AUC of 0.8033 (internal validation) and 0.7353 (external validation). The correction effect of the calibration was satisfactory and the DCA decision curve analysis showed a strong clinical practicability.

CONCLUSION

the nomogram risk prediction model of LNM has been established for EGC patients to assist in formulating personalized treatment plans.

An examination of surgical and survival outcomes in the elderly (65-79 years of age) and the very elderly (≥80 years of age) who received surgery for gastric cancer

Objective: The purpose of this study was to examine surgical and survival outcomes in the elderly (65-79 years of age) and the very elderly (≥80 years of age) who received surgery for gastric cancer.Methods: This study retrospectively reviewed the records of patients ≥65 years old who received a gastrectomy for gastric adenocarcinoma. Demographic, clinical, and pathological data were extracted from the medical records. Patients were divided into two groups: those 65-79 years of age and those ≥80 years of age. Data and survival outcomes were compared between the groups.Results: Sixty-four patients were included, 32 males and 32 females. The mean age in the 65-79 years old group was 73.4 ± 4.5 years, and in the ≥80 years group was 85.2 ± 3.4 years (p < .001). Three patients in the older group had chronic kidney disease, as compared to none in the 65-79 years group (p = .04); all other demographic, clinical, tumor, and surgical characteristics were similar between the groups, except for surgical time (all, p > .05). Patients ≥80 years had a higher incidence of pulmonary complications (24% vs 4.7%, p = .03), but there was no significant difference in in-hospital mortality. The ≥80 years group had a higher overall survival, but the difference between the groups was not statistically significant (42.9% and 34.9%, p = .224).Conclusions: Curative intent resection, gastrectomy with D1+/D2 lymph node dissection is a viable option for elders ≥80 years old with gastric carcinoma.

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.

Clinical significance of prognostic score based on age, tumor size, and grade in gastric cancer after gastrectomy

Background

Postoperative management and survival of gastric cancer is mainly determined by pathologic TNM stage. However, gastric cancer is a heterogeneity group, and the survival is quite different even when they are in the same TNM stage. Moreover, TNM stage system does not grasp other important clinicopathologic factors to determine the survival. The aim of the present study is to propose and validate prognostic score based on age, tumor size, and grade.

Materials and methods

Patients diagnosed with gastric cancer in the Surveillance, Epidemiology, and End Results database from 1988 to 2012 were included in the present study. Kaplan-Meier methods were adopted and multivariable Cox regression models were built for the analysis of long-term survival outcomes and risk factors.

Results

A total of 26,091 eligible patients diagnosed with noncardia gastric cancer were included in the study. In the univariate and multivariate survival analysis, age at diagnosis, tumor grade, and tumor size were validated as independent prognostic factors (P<0.05). Then, we proposed a prognostic score calculated from the number of risk factors, with 0, 1, and 2 points each given for favorable, intermediate, and poor prognostic categories of age (≤50, 50-70, and >70), grade (well, moderate, and poor differentiation), and size (≤3, 3-6, ≥7 cm). The prognostic score was verified as independent predictor in both univariate and multivariate survival analyses (P<0.001). In addition, nomograms on cause-specific survival were established according to prognostic factor and all other significant factors, and c-index was 0.715 (95% CI: 0.706-0.725).

Conclusion

Prognostic score based on age, tumor size, and grade is an independent predictor of survival after gastrectomy. The novel prognostic score can improve the accuracy of prediction for current TNM stage system. Patients who are with a high prognostic score should undergo extensive follow-up after surgery.

The Characteristics, Prognosis, and Risk Factors of Lymph Node Metastasis in Early Gastric Cancer

Background

Lymph node metastasis (LNM) is the most important risk factor for endoscopic treatment in early gastric cancer (EGC) patients. We aimed to investigate the rate of LNM, the risk factors, and the prognosis of EGC patients with LMN.

Methods

A total of 10,039 patients who underwent gastrectomy with lymphadenectomy were reviewed between January 2010 and December 2015 at Jiangsu Province Hospital in China. Among them, we identified 1004 (10%) EGCs. First, endoscopic and clinicopathological features related to LNM were analyzed, and then risk factors for LNM were identified using univariate and multivariate analysis. Finally, the short- and long-term outcomes were compared between the groups.

Results

LNM occurred in 123 (12.3%) EGCs. Most of EGCs were male (n = 720, 71.7%) and mean age was 59.65 ± 11.09 years. The rate of H. pylori infection was 78.0% (783/1004). LNM was significantly associated with age, sex, location, lesion size, macroscopic type, depth of invasion, differentiation type, histological morphology, lymphovascular invasion (LVI), and TMN stage. By multivariate analysis, significant independent risk factors for LNM in EGC were identified as following: male sex (OR 2.365, P = 0.035), age ≦ 40 (OR 0.055, P = 0.012), depressed type (OR 2.721, P = 0.013), submucosa invasion (OR 2.987, P = 0.032), LVI (OR 5.186, P = 0.003), tumor located in corpora (OR 8.904, P = 0.047), and in angle (OR 12.998, P = 0.024). 86.5% were successfully followed up for 3 years. The overall 1- and 3-year survival rates in LNM group were 100% and 91.1%, respectively, and those with no LNM were 100% and 100%, respectively.

Conclusion

EGCs were investigated in 10.0% of gastric cancer, which LNM occurred in 12.3% of EGC. Independent risk factors of LNM included male sex, age (>40), the depth of invasion, LVI, and tumor located in corpora or angle. The 3-year overall survival rate was greater in EGC patients without LNM.

Clinicopathological features and prognosis in elderly gastric cancer patients: a retrospective cohort study

Background

Little is known about the clinicopathological features and prognosis in elderly gastric cancer (GC) patients aged 65–79 years. The aim of this study was to evaluate clinicopathological features and prognosis in elderly GC patients.

Patients and methods

From May 2008 to December 2014, a total of 5,282 GC patients were enrolled in our present study. Patients were divided into elderly and middle-aged groups. The clinicopathological features and clinical outcomes were analyzed.

Results

The proportion of dysphagia was significantly higher in elderly patients than that in middle-aged patients (P=0.002), whereas the proportion of abdominal pain and heartburn was significantly lower in elderly patients than that in middle-aged patients (P<0.001 vs P=0.038, respectively). The proportion of patients with carbohydrate antigen (CA) 19-9 was significantly higher in elderly patients than that in middle-aged patients (P=0.009). There was no significant difference in clinicopathological features between elderly and middle-aged patients with D2 gastrectomy (all P>0.05). Age, tumor size, histological type, tumor depth, lymph node metastasis, carcinoembryonic antigen, alpha fetoprotein, CA19-9, and CA125 were independent risk factors for the prognosis of GC patients in univariate and multivariate analyses. Overall survival in elderly patients was significantly reduced compared with middle-aged patients (P=0.001), especially in patients with tumor size >5 cm (P=0.002), poorly differentiated tumor (P<0.000), stage III tumor (P=0.002), or normal levels of carcinoembryonic antigen (P=0.009), alpha fetoprotein (P=0.002), CA19-9 (P=0.002), and CA125 (P=0.004).

Conclusion

The clinicopathological features of elderly patients were different to those of middle-aged patients. The prognosis for elderly GC patients was significantly worse than for middle-aged patients.

Characteristics of advanced gastric cancer with negative or only perigastric lymph node metastasis in elderly patients

OBJECTIVES

After gastrectomy with extended lymph node (LN) dissection, the damage of celiac plexus seems to cause of disorder of eating habits. To clarify the indication of gastrectomy with limited LN dissection for elderly patients, the pathological characteristics of advanced gastric cancer in elderly patients were examined in this study.

METHODS

Forty-seven patients aged ≥80 years with advanced gastric cancer (deeper than pT2) who underwent curative gastrectomy from 1998 to 2015 were enrolled. Patients were classified into two groups by extent of LN metastasis: Group A, with N0 or only perigastric LN metastasis (n = 33); Group B, LN metastasis beyond the perigastric area (n = 14). Pathological factors were then evaluated.

RESULTS

No significant differences were observed in age, sex, body mass index, American Society of Anesthesiologists physical status classification, serum level of carcinoembryonic antigen, surgical procedure, extent of LN dissection, and number of dissected LNs. Pathological findings showed no significant differences in tumor location, macroscopic type, histologic type, and lymphovascular invasion. However, significant differences were observed in tumor maximum diameter at the cut-off level of 40 mm (Group A: ≤40 mm, n = 10 and >40 mm, n = 23; Group B: ≤40 mm, n = 0 and >40 mm, n = 14; P = 0.02).

CONCLUSION

In the elderly patients, LN metastasis in advanced gastric cancer of ≤40 mm in diameter was limited to be within the perigastric area. Gastrectomy with only perigastric LN dissection may be adopted in these patients.

Efficacy and safety of SOX chemotherapy with or without surgery in AFP-producing advanced gastric cancer

The present study investigated the clinical efficacy of S-1 plus oxaliplatin (SOX) regimen, with or without surgery in α-fetoprotein-producing gastric cancer (APGC) with liver metastasis. A total of 24 patients with APGC treated at the Liaocheng People's Hospital between January 2011 and December 2013 were retrospectively reviewed. Clinical efficacy and patient safety were compared between the two groups. The median progression-free survival (PFS) and overall survival (OS) in the SOX group were 6.5 [95% confidence interval (CI), 4.6–8.4] and 13.5 (95% CI, 8.1–18.9) months, respectively. The corresponding indicators in the SOX and surgery group were 7.0 (95% CI, 5.7–8.3) and 14 (95% CI, 11.0–17.1) months, respectively. There was no significant difference in PFS and OS between the two groups (P=0.703 and 0.710, respectively). The adverse effects of leucopenia, neutropenia, anemia and diarrhea occurred in ~10% of patients in the SOX group and in 14.3% (2/14), 7.14% (1/14), 14.3% (2/14) and 7.14% (1/14), respectively, in the surgery group. No significant difference was identified between groups in terms of overall incidence of adverse effects (P=0.17). However, severe adverse events, including gastroplegia, pancreatic fistula, pulmonary infection and refractory ascites, occurred only in the SOX plus surgery group [incidence rate for severe adverse events, 7.14% (1/14); P<0.001 between groups]. In conclusion, SOX chemotherapy is safe and effective in patients with APGC and liver metastasis. However, the addition of surgery to SOX chemotherapy may not improve the disease control rate and may increase the adverse effects.

Differences in the prognosis of early gastric cancer according to sex and age

BACKGROUND

Few studies have compared early gastric cancer (EGC) outcomes according to sex and age.

METHODS

We retrospectively reviewed 2085 patients who underwent curative gastrectomy for EGC between 1989 and 2000. Prognosis and risk factors for nodal involvement were evaluated according to sex and age.

RESULTS

Male sex and age were independent prognostic factors for overall survival (OS) but not relapse-free survival (RFS). In young (⩽55 years) patients, there were no significant differences in RFS and OS between men and women. However, older (>55 years) men had a poorer OS and older women had a poorer RFS. Young female patients had a higher proportion of gastric cancer-related death than young male patients. Female sex was an independent risk factor for nodal involvement in younger patients.

CONCLUSIONS

Young women with EGC should be more intensively treated and monitored than other patient groups and should not be treated by endoscopic resection.

Effect of low-molecular heparin on therapeutic effect and renal function in patients with gastric cancer

AIM

To evaluate the effect of low-molecular heparin on therapeutic effect and renal function in patients with gastric cancer.

METHODS

Ninety-six patients with gastric carcinoma treated at our hospital from May 2013 to December 2015 were randomly divided into either a control group or an observation group, with 48 cases in each group. The control group was treated with standard chemotherapy, and the observation group was additionally given subcutaneous injections of low molecular heparin on the basis of standard chemotherapy. Therapeutic effect, rate of complications, and renal damage index were compared between the two groups.

RESULTS

After two courses of treatment, the total effective rate was significantly higher in the observation group than in the control group (85.42% vs 64.58%, χ² = 5.556, P = 0.018); blood urea nitrogen, serum creatinine, albumin/serum creatinine ratio, and urine N-acetyl-β-D-glucosamidase/serum creatinine ratio were significantly lower in the observation group than in the control group (P < 0.01); and the rates of gastrointestinal reaction, deep venous thrombosis, pulmonary embolism and liver and kidney dysfunction were significantly lower in the observation group than in the control group (P < 0.05). However, the incidence of bleeding in the two groups showed no significant difference (P > 0.05).

CONCLUSION

Treatment with low-molecular heparin can obviously improve the therapeutic effect in gastric cancer patients, shorten the treatment course, and reduce the economic burden of the family, and is associated with fewer complications in gastric cancer patients. Low-molecular heparin has obvious anticoagulant effect and can improve renal function in patients with gastric cancer.

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

The global aging of population will lead a greater number of elderly patients to undergo surgical procedure in a near future. Concerning gastric cancer, the impact of lymphadenectomy on survival has been demonstrated in RCTs, and extended lymphadenectomy is now considered as gold standard of treatment in non-early tumors. However, the role of age as a prognostic factor and the benefit of extended surgery in elderly/high-risk patients are not clearly defined yet. From our revision of literature, it seems that surgery for gastric cancer may have a further tailorization, considering not only the stage of disease, but also patients' age and comorbidities.

Clinicopathologic Characteristics of Elderly with Gastric Cancer, and the Risk Factors of Postoperative Complications

PURPOSE

In China, gastric cancer (GC), which is one of the most common malignant tumors, has an increasing incidence in elderly population due to aging process. Since a considerable number of elderly patients with GC accepting surgical treatments developed postoperative complications, it is necessary to evaluate risk factors for postoperative complications.

MATERIALS AND METHODS

In the present study, the clinicopathologic characteristics of 3,024 elderly patients (aged ≥65 years) with GC, who underwent surgery between 1996 and 2006, were examined and contributing factors for postoperative complications were analyzed. A total of 2,915 non-elderly patients (aged <65 years) with GC during the same period were enrolled as a control group. Clinicopathologic characteristics of non-elderly patients were investigated and compared with elderly group.

RESULTS

As to clinicopathologic characteristics, significant differences were detected in terms of location of primary lesions between elderly patients and non-elderly patients (p <.05), whereas no statistical difference was observed in other characteristics between two groups (p >.05). Surgical property and method in elderly patients were similar to that in non-elderly patients (p >.05). Regression analysis showed that diabetes, chronic pulmonary disease, preoperative anemia, preoperative hypoalbuminemia, combined organ excision, and blood transfusion were independent factors for complications in elderly patients (p <.05), with some differences from non-elderly group.

CONCLUSIONS

Elderly group with GC had distinctive clinicopathologic characteristics. Surgery remains principal treatment for elderly, and proper preoperative measures are required to decrease postoperative complications.

Short and long-term outcomes after gastrectomy for gastric carcinoma in elderly patients

As worldwide life expectancy rises, the number of candidates for surgical treatment of gastric carcinoma over 70 years will increase. This study aims to examine outcomes after gastric carcinoma in elderly patients. This study is a retrospective review of 697 patients undergoing gastrectomy with radical intent for gastric carcinoma during January 2007 to January 2013. A total of 534 patients were less than 70 years old (group A), and 163 patients 70 years or greater (group B). We analyzed the effect of age on short and long-term variables including overall survival and disease-free survival. Major morbidity was observed to occur in 19 patients of group A, and 15 of group B. Mortality, both 30-day and 90-day was observed in 1 and 3 of group A, and 3 and 6 of group B. Five-year overall survival and disease-free survival was 61% and 60% for group A, 50% and 43% for group B respectively. Gastrectomy should be carefully considered in patients 70 years old and can be justified with low mortality and acceptable long-term outcomes.