Treatment of early gastric cancer in the Western World

Totally robotic proximal gastrectomy with esophagogastrostomy using a double-flap technique

Proximal gastrectomy (PG) with D1 + lymphadenectomy and anti-reflux reconstruction is a standard surgical procedure for early-stage (EGC) proximal gastric cancer (PGC) in the East. The double-flap technique (DFT) for esophagogastrostomy has been established as an optimal anti-reflux reconstructive method after PG. However, its technical difficulty makes it a procedure not yet performed in the West. We present the technique of robotic PG with D1 + lymphadenectomy and DFT. The technique was learned during a period of attendance at the National Cancer Center Hospital East, Japan. A 70-year-old patient was submitted to endoscopic submucosal dissection for EGC-PGC. The pathologic report showed pT1b R1 disease. Additional surgery was recommended. Surgery was accomplished via a totally robotic approach (da Vinci Xi Surgical System). The patient was placed in a supine position with legs apart. Four robotic trocars and two laparoscopic trocars were placed above the transversal umbilical line. The surgical steps are summarized as follows: opening of the lesser omentum; dissection of the abdominal esophagus and lymphadenectomy of no. 1, 2 stations; partial omentectomy with lymphadenectomy of no. 4sa and 4sb stations and ligation of the left gastro-epiploic vessels; lymphadenectomy of no. 3a, 7, 8a, 9, 11p stations; transection of the esophagus; proximal gastrectomy; dissection of the posterior aspect of the remnant stomach; creation of the seromuscular flap; posterior esophageal suspension; anastomosis; flap closure. Pathology report showed the absence of residual disease with 27 lymph nodes collected from the specimen. After 1 year, the patient is disease free; no reflux esophagitis, weight loss, or anastomotic stricture was reported on follow-up. To the best of our knowledge, no other previous cases have been reported in the West describing the present surgical technique. The authors propose that PG with DFT seems feasible in a Western setting, representing an important and desirable skill for any referral center for gastric cancer surgical oncology.

Downregulation of Hedgehog Interacting Protein (HHIP) in Gastric Cancer: Implications for Tumorigenesis

The increasing incidence of gastric cancer (GC) in the Kashmir Valley is concerning, but its root causes are largely unknown. Dysregulated activation of the Hedgehog signaling pathway has been linked to various cancers, and the Human Hedgehog Interacting Protein (HHIP), a tumor suppressor, is frequently dysregulated in malignancies. However, the expression of the HHIP gene in GC is inconsistent and poorly understood. This study aimed to examine HHIP gene expression in gastric cancer. We used methylation-specific PCR, Western Blot analysis, and quantitative reverse transcription PCR (qRT-PCR) to assess the hypermethylation and expression levels of HHIP gene promoters. The correlation between these results and clinical parameters (e.g. age, gender, histological type, class, stage, and lymph node metastasis) was studied with samples from 53 GC patients confirmed by histology. In 69.81% (37 out of 53) of the tumor tissue, HHIP hypermethylation was found. Of the 45 cases examined for mRNA expression, 53.33% (24 out of 45) showed a decrease in the HHIP mRNA level compared to the normal sample. In addition, 49.05% (26 out of 53) showed a decline in the expression of HHIP proteins. Almost all GC samples with reduced protein expression also showed a reduction in mRNA levels. These results suggest that the hypermethylation of the HHIP promoter leads to a decrease in the regulation of HHIP, which contributes to the activation of the hedgehog signal path and may play a critical role in the progress of GC. Our study highlights the significant link between HHIP hypermethylation and reduced gene expression at both mRNA and protein levels, suggesting that target HHIP gene methylation could be a promising treatment strategy for gastric cancer.

Clinical epidemiology of the endoscopic, laparoscopic, and surgical resection of malignant gastric tumors in Japan, 2014-2021: a retrospective study using open data from a national claims database

BACKGROUND

Gastric cancer is a common malignancy with a high incidence in East Asia. Gastric resection ranges from endoscopic resection to open total gastrectomy. However, nationwide data are lacking.

METHODS

This observational study analyzed data from the publicly accessible National Database of Health Insurance Claims and Specific Health Checkups, which includes most national health insurance claims data in Japan. Trends in the types of resection performed for malignant gastric tumors between 2014 and 2021, patients' age and sex distributions, and regional disparities were investigated.

RESULTS

The annual number of resections was highest in 2015 (109,000) and lowest in 2020 (90,000) after the COVID-19 pandemic. The proportion of endoscopic resections increased from 47% in 2014 to 57% in 2021 while that of total gastrectomies decreased from 17 to 10%. In 2021, 70% of patients who underwent resection were men. That year, 83.8% of all patients who underwent any type of gastric resection and 87.1% of those who underwent endoscopic submucosal dissection were aged ≥ 65 years. The annual incidence of gastric resection per million population was highest in Tottori (n = 1236) and lowest in Okinawa (n = 251). The proportion of endoscopic resections was highest in Miyagi (66%) and lowest in Aichi (45%) and that of open surgery was highest in Aomori (36%) and lowest in Wakayama (5%).

CONCLUSIONS

Gastric malignancy is increasingly treated by endoscopic submucosal dissection rather than open total gastrectomy. However, regional disparities remain in resection type. Standardization of treatment and a more even distribution of specialists are needed.

Genomic events stratifying prognosis of early gastric cancer

BACKGROUND

The purpose of the study was to conduct a comprehensive genomic characterization of gene alterations, microsatellite instability (MSI), and tumor mutational burden (TMB) in submucosal-penetrating (Pen) early gastric cancers (EGCs) with varying prognoses.

METHODS

Samples from EGC patients undergoing surgery and with 10-year follow-up data available were collected. Tissue genomic alterations were characterized using Trusight Oncology panel (TSO500). Pathway instability (PI) scores for a selection of 218 GC-related pathways were calculated both for the present case series and EGCs from the TCGA cohort.

RESULTS

Higher age and tumor location in the upper-middle tract are significantly associated with an increased hazard of relapse or death from any cause (p = 0.006 and p = 0.032). Even if not reaching a statistical significance, Pen A tumors more frequently present higher TMB values, higher frequency of MSI-subtypes and an overall increase in PI scores, along with an enrichment in immune pathways. ARID1A gene was observed to be significantly more frequently mutated in Pen A tumors (p = 0.006), as well as in patients with high TMB (p = 0.027). Tumors harboring LRP1B alterations seem to have a higher hazard of relapse or death from any cause (p = 0.089), being mutated mainly in relapsed patients (p = 0.093).

CONCLUSIONS

We found that the most aggressive subtype Pen A is characterized by a higher frequency of ARID1A mutations and a higher genetic instability, while LRP1B alterations seem to be related to a lower disease-free survival. Further investigations are needed to provide a rationale for the use of these markers to stratify prognosis in EGC patients.

The role of cuproptosis in gastric cancer

As a biologically essential transition metal, copper is widely involved in various enzymatic reactions and crucial biological processes in the body. It plays an increasingly important role in maintaining normal cellular metabolism and supporting the growth and development of the human body. As a trace element, copper maintains the dynamic balance of its concentration in body fluids through active homeostatic mechanisms. Both excess and deficiency of copper ions can impair cell function, ultimately leading to cell damage and death. Cuproptosis is a novel form of cell death where copper ions cause cell death by directly binding to the lipoylated components of the citric acid cycle (CAC) in mitochondrial respiration and interfering with the levels of iron-sulfur cluster (Fe-S cluster) proteins, ultimately causing protein toxic stress. Its primary characteristics are Cu2+ concentration dependence and high expression in mitochondrial respiratory cells. Recent research has revealed that, compared to other forms of programmed cell death such as apoptosis, necrosis, and autophagy, cuproptosis has unique morphological and biochemical features. Cuproptosis is associated with the occurrence and development of various diseases, including cancer, neurodegenerative diseases, and cardiovascular diseases. This article focuses on a review of the relevance of cuproptosis in gastric cancer (GC).

Defining a balance by compromising with fear: A grounded theory study on returning to eating after a total gastrectomy

OBJECTIVES

Gastric cancer patients undergoing total gastrectomy face nutrition-related complications and worsening quality of life after surgery. In this context, gastrectomized cancer patients are required to cope with new conditions. Little is known about their accommodating feeding to the new life condition as a negotiated process among stakeholders in real contexts. This study aimed to investigate the shaping of this process as influenced by the perspectives of patients, health-care professionals (HPs), and caregivers (CGs).

METHODS

A constructivist grounded theory study, through semi-structured interviews and interpretative coding, was designed to answer the following research question: "what is the process of returning to eating and feeding after a gastrectomy?"

RESULTS

The final sample included 18 participants. "Defining a balance by compromising with fear" is the core category explaining returning to eating as a process negotiated by all actors involved, with patients trying to find a feeding balance through a multi-layer compromise: with the information received by HPs, the proprioception drastically altered by gastric resection, new dietary habits to accept, and complex and often minimized conviviality. This process involves 4 main conceptual phases: relying on the doctors' advice, perceptive realignment, rearranging food intake, and food-regulated social interaction. Those categories are also shaped by the fear of being unwell from eating and the constant fear of tumor relapse.

SIGNIFICANCE OF RESULTS

Multiple actors can meet patients' and their CGs' nutritional, care, and psychosocial needs. A multidisciplinary approach involving nutritionists, psychologists, occupational therapists, social workers, and anthropologists can be key to effectively managing these patients' survivorship care. We suggest training all the professionals on the first level of nutritional counseling.

Premature mortality for patients after completely resected early adenocarcinoma of the esophagus or stomach

OBJECTIVE

To establish the life expectancy burden of esophago-gastric cancer by analyzing years of life lost (YLL) for a Western patient population after treatment of early esophageal (EAC) or early gastric (GAC) adenocarcinoma.

BACKGROUND

For patients with early EAC or GAC, the short-term prognosis after surgical resection is very good. Little data is available regarding long-term prognosis when compared to the general population.

METHODS

Two hundred and fourteen patients with pT1 EAC (n = 112) or GAC (n = 102) were included in the study. Patients with EAC underwent transthoracic en-bloc esophagectomy; those with GAC had total or subtotal gastrectomy with D2-lymphadenectomy. Surviving patients had a median follow-up of approximately 14 years. YLL was calculated using average life expectancy data from Germany.

RESULTS

Patients with EAC were younger (median age 61 years) than those with GAC (66 years) (p = 0.031). The male:female ratio was 10:1 for EAC and 3:2 for GAC (p < 0.001). Multivariate survival analysis showed the age of the patients ≥60 years and the existence of lymph node metastasis was associated with poor prognosis. The median YLL for all patients who died over follow-up was 8.0 years. For patients under 60 years, it was approximately 20 years, and for older patients, approximately 5 years (p < 0.001) without difference in tumor stage between these age cohorts. YLL did not differ for GAC vs. EAC.

CONCLUSION

After surgical resection, the prognostic burden as measured by YLL is relevant for all patients with early esophageal and gastric adenocarcinomas and especially for younger patients. Reasons for YLL need further studies.

Association of tumour mutation burden with prognosis and its clinical significance in stage III gastric cancer

Introduction

To explore the correlation between the tumour mutation burden (TMB) and prognosis and its clinical significance among patients with stage III gastric cancer (GC).

Methods

Patients with stage III GC were divided into a high TMB and low TMB group in both a study cohort of 38 patients and the Cancer Genome Atlas (TCGA) cohort of 173 patients. In the study cohort, next-generation sequencing was used to detect mutated GC genes and obtain TMB data. In the TCGA cohort, gene set enrichment analysis was performed, and the relationship between TMB, prognosis and clinicopathologic factors was analysed. Western blot and quantitative real-time polymerase chain reaction were used to detect the expression levels of both proteins and genes. Cell viability was measured using methyl thiazolyl tetrazolium and transwell cell assays.

Results

Patients in the high TMB group had better overall survival (OS) rates than patients in the low TMB group for both cohorts and TMB was associated with age, mutation signature 1 and mutation signature 17. The Cox regression analysis revealed that age, not TMB, was an independent prognosis factor. Furthermore, genes with high-frequency mutations were significantly enriched in the RTK-RAS and Notch signalling pathways. The activation of these pathways was lower in the high TMB compared with the low TMB group, and the proliferation and migration abilities of GC cells showed a similar pattern in both TMB groups.

Conclusion

Patients in the high TMB group had better OS rates than patients in the low TMB group. Genes with high-frequency mutations were significantly enriched in the RTK-RAS and Notch pathways. Hence, TMB could serve as a prognosis biomarker with potential clinical significance.

Early-onset gasrtric cancer (review)

Objective. Early-onset gastric cancer (EOGC) constitutes a serious medical and social problem. Early-onset gastric cancer accounts for approximately 6% of all malignant epithelial neoplasms.

Material and Methods. We reviewed retrospective and prospective randomized trials using Medline and Elibrary databases.

Results. The applied significance of the molecular genetic classifications consist in the formation of groups for evaluating prognosis of the disease using multifactorial analysis. This classification indicates that EOGC diagnosed at a locally advanced stage and primary dissemination is most often caused by GS (TCGA) and MSS/EMT(ACRG) subtypes and is characterized by mutations in CDH1, RhoA, CLDN18-ARHGAP genes. These changes are accompanied by the prevalence of diffuse histological type of gastric cancer according to the Lauren classification and ulcerated or infiltrative type according to the Borrmann classification (type III and IV) with the presence of high-grade adenocarcinoma with a signet ring cell component.

Conclusion. Considering the aggressiveness of gastric cancer in young patients, who more frequently present with locally advanced and metastatic disease at the time of diagnosis, there is a need for increased cancer alertness among physicians of other specialties, early endoscopic controls to detect cancer at early stages and benefit from both surgical and multimodal treatment.

"Evaluation of quality of life in patients with gastric adenocarcinoma receiving chemoradiotherapy: a cross-sectional study"

PURPOSE

The aim of this study was to evaluate quality of life (QoL) in patients with gastric adenocarcinoma receiving adjuvant chemoradiotherapy (CRT).

METHODS

The European Organization for Cancer Research and Treatment Quality of Life Questionnaire-Core 30 (QLQ-C30) and site-specific module for gastric cancer (QLQ-STO22) were administered at four time points to 156 patients admitted to Cumhuriyet University Oncology Center between 2011 and 2018.

RESULTS

The patient group comprised 76% men and 24% women with a median age of 61 years (range, 18-88). During CRT, 12 patients (8%) discontinued treatment, 25 (16%) lost weight, and 42 (27%) had reduced performance. There was significant worsening in QLQ-C30 global health status and all functional and symptom scale scores at CRT completion. These changes were also clinically significant except for physical functioning scores and were supported by minimal clinically important difference measurements. In the QLQ-STO22, all symptoms except dry mouth and hair loss were negatively affected at CRT completion. In general, scores were improved at 1 month after CRT and almost all scores reached baseline level by 6 months. Certain scores were more adversely affected in women (global health status, physical functioning, role functioning, fatigue, pain, and insomnia), those who lost weight during CRT (emotional functioning), and those with CRT interruption (emotional functioning and anxiety).

CONCLUSION

Although CRT reduces QoL in patients with gastric cancer, the effects tend to resolve within 6 months after completing treatment. Female sex, weight loss, and CRT interruption negatively affected some QoL scores.

Gastric cancer risk in the elderly is associated with omeprazole use and inversely associated with aspirin use

BACKGROUND

The association between long-term omeprazole use and gastric cancer (GC) risk is controversial. The aim of this study was to investigate the incidence of GC in elderly community-dwelling omeprazole chronic users with/without aspirin compared to non-users.

METHODS

The registry of a large health management organization was searched for all community-dwelling members aged ≥65 years from January 2002 to December 2016. Data on demographics, background parameters, and chronic omeprazole and aspirin use (>11 prescriptions/year) were retrieved. Those diagnosed with new-onset GC during the study period (from January 2003) were identified.

RESULTS

Of 51 405 subjects who met the inclusion criteria, 197 were diagnosed with GC during a mean follow-up period of 8.74 ± 4.16 years. This group accounted for 0.7% of PPI chronic users (72/11 008) and 0.3% (125/40 397) of nonusers (P < 0.001). GC risk was directly associated with omeprazole chronic use [hazard ratio (HR) 2.03, 95% confidence interval (CI): 1.51-2.73, P < 0.001] and inversely associated with aspirin chronic use (HR 0.55, 95% CI: 0.40-0.75, P < 0.001). Each year of omeprazole use increased GC risk by 9%, and each year of aspirin use decreased GC risk by 10% among omeprazole chronic users. The lowest rate of GC was found in omeprazole nonusers/ aspirin chronic users, and the highest, in omeprazole chronic users/aspirin nonusers.

CONCLUSION

Higher GC rate was associated with omeprazole chronic use and inversely associated with aspirin chronic use relative to omeprazole nonuse in community-dwelling elderly.

Positive lymph node ratio as a prognostic factor for gastric cancer patients: Is it going to supersede positive lymph node number in guidelines?

Gastric malignancies constitute the sixth most common cancer with regards to incidence and have the fifth most mortality rates. Extended lymph-node dissection is the surgical modality of choice while treating advanced stage gastric cancer. It is yet a topic of debate, whether or not the amount of positive lymph nodes after a pathological examination following the surgical intervention is of prognostic value. In this study, it is aimed to evaluate the prognostic significance of positive lymph nodes following the surgery. A total of 193 patients who underwent curative gastrectomy between January 2011 and December 2015 have been considered for a retrospective data collection. The cases with R1-R2 resections, palliative or emergent surgeries are excluded. Metastatic to total number of lymph nodes, corresponded a ratio which was analyzed in this survey and practiced as a predictive parameter of disease outcome. This survey includes 138 male (71.5%) and 55 female (28.5%) patients treated between 2011 and 2015 in our clinic. The survey follow-up duration of the cases range between 0, 2, and 72 months, corresponding an average of 23.24 ± 16.99 months. We calculated cutoff value of 0.09 with, sensitivity is 76.32% for positive to total number of lymph nodes ratio, whereas specivity applies for 64.10%, positive predictive value for 58% and negative predictive value for 80.6%. Positive lymph node ratio has a prognostic value in terms of predicting the prognosis of the patients with gastric adenocarcinoma following a curative gastrectomy. This might in long term contribute to the prognostic analysis of patients if integrated in the current staging system.

Emetine, a small molecule natural product, displays potent anti-gastric cancer activity via regulation of multiple signaling pathways

BACKGROUND

Gastric cancer (GC) is a life-threatening malignant tumor with high incidence rate. Despite great progress, there are still many GC sufferers that cannot benefit from the existing anti-GC treatments. Therefore, it is still necessary to develop novel medicines against GC. Emetine, a natural small molecule isolated from Psychotria ipecacuanha, has been broadly used for medicinal purposes including cancer treatment. Here, we conducted a comprehensive study on the anti-GC effects of emetine and the related mechanisms of action.

METHODS

The cell viability was evaluated by MTT and colony formation assay. Cellular proliferation and apoptosis were analyzed by edu incorporation assay and Annexin V-PI staining, respectively. Moreover, wound healing assay and transwell invasion assay were conducted to detect cell migration and invasion after treatment with emetine. To elucidate the molecular mechanism involved in the anti-GC effects of emetine, RNA sequencing and functional enrichment analysis were carried out on MGC803 cells. Then, the western blot analysis was performed to further verify the anti-GC mechanism of emetine. In vivo anti-tumor efficacy of emetine was evaluated in the MGC803 xenograft model.

RESULTS

MTT and colony formation assay exhibited a strong potency of emetine against GC cell growth, with IC₅₀ values of 0.0497 μM and 0.0244 μM on MGC803 and HGC-27 cells, respectively. Further pharmacodynamic studies revealed that emetine restrained the growth of GC cells mainly via proliferation inhibition and apoptosis induction. Meanwhile, emetine also had the ability to block GC cell migration and invasion. The results of RNA sequencing and western blot showed that emetine acted through regulating multiple signaling pathways, including not only MAPKs and Wnt/β-catenin signaling axes, but also PI3K/AKT and Hippo/YAP signaling cascades that were not found in other tumor types. Notably, the antitumor efficacy of emetine could also be observed in MGC803 xenograft models.

CONCLUSION

Our data demonstrate that emetine is a promising lead compound and even a potential drug candidate for GC treatment, deserving further structural optimization and development.

Inhibition of TRF2 Leads to Ferroptosis, Autophagic Death, and Apoptosis by Causing Telomere Dysfunction

Background

Gastric cancer (GC) is an aggressive malignancy with a high mortality rate and poor prognosis. Telomeric repeat-binding factor 2 (TRF2) is a critical telomere protection protein. Emerging evidence indicates that TRF2 may be an essential treatment option for GC; however, the exact mechanism remains largely unknown.

Objective

We aimed to explore the role of TRF2 in GC cells. The function and molecular mechanisms of TRF2 in the pathogenesis of GC were mainly discussed in this study.

Methods

Relevant data from GEPIA and TCGA databases regarding TRF2 gene expression and its prognostic significance in GC samples were analyzed. Analysis of 53BP1 foci at telomeres by immunofluorescence, metaphase spreads, and telomere-specific FISH analysis was carried out to explore telomere damage and dysfunction after TRF2 depletion. CCK8 cell proliferation, trypan blue staining, and colony formation assay were performed to evaluate cell survival. Apoptosis and cell migration were determined with flow cytometry and scratch-wound healing assay, respectively. qRT-PCR and Western blotting were carried out to analyze the mRNA and protein expression levels after TRF2 depletion on apoptosis, autophagic death, and ferroptosis.

Results

By searching with GEPIA and TCGA databases, the results showed that the expression levels of TRF2 were obviously elevated in the samples of GC patients, which was associated with adverse prognosis. Knockdown of TRF2 suppressed the cell growth, proliferation, and migration in GC cells, causing significant telomere dysfunction. Apoptosis, autophagic death, and ferroptosis were also triggered in this process. The pretreatment of chloroquine (autophagy inhibitor) and ferrostatin-1 (ferroptosis inhibitor) improved the survival phenotypes of GC cells.

Conclusion

Our data suggest that TRF2 depletion can inhibit cell growth, proliferation, and migration through the combined action of ferroptosis, autophagic death, and apoptosis in GC cells. The results indicate that TRF2 might be used as a potential target to develop therapeutic strategies for treating GC.

Global scientific trends in laparoscopy and gastric cancer in the 21st century: A bibliometric and visual mapping analysis

Aims

To use visual mapping and bibliometrics to analyze and summarize the valuable information on laparoscopic surgery for gastric cancer (GC) obtained in the last 20 years, so as to determine the research hotspots and trends in this field.

Methods

We screened all literature on laparoscopic surgery for GC in the Web of Science published from 2000 to 2022 and analyzed the research hotspots and trends in this field using VOSviewer.

Results

A total of 2796 reports from 61 countries and regions were selected. Japanese researchers published the most papers (n=946), followed by those from China (n=747) and South Korea (n=557). Papers from Japan also had the most citations (n=21,836). Surgical Endoscopy and Other Interventional Techniques published the most reports on laparoscopic surgery for GC (n=386) and also had the highest total number of citations (n=11,076), making this journal the most authoritative in this field. Among the institutions, researchers from Seoul National University in South Korea had the highest numbers of published papers and citations. The keywords of the articles could be divided into five categories: surgical methods for GC, short-term and long-term efficacy of laparoscopic surgery, guiding role of laparoscopy in the treatment of advanced GC, diagnosis and treatment of early gastric cancer (EGC), and lymph node dissection. Keywords such as "laparoscopic proximal gastrectomy", "surgical outcomes", and "esophagogastric junction" have emerged recently, and relevant studies on laparoscopic surgery for adenocarcinoma of esophagogastric junction(AEG)have gradually become a hot topic and trend.

Conclusion

This study adopted bibliometric analysis to identify the current research hotspots and research trends in the field of laparoscopic surgery for GC. Five main research hotspots of laparoscopic surgery for GC were also identified. Laparoscopic surgery for AEG may become an important research focus in the future.

Comprehensive analysis of treatment-related adverse events of immunotherapy in advanced gastric or gastroesophageal junction cancer: A meta-analysis of randomized controlled trials

AIMS

Immune checkpoint inhibitors (ICIs) have been recognized as an effective treatment for advanced gastric or gastroesophageal junction cancer (AG/GEJC). However, the safety of ICIs in patients has not been established. We aimed to systematically assess the risk of all common treatment-related adverse events (TRAEs) in immunotherapy of AG/GEJC.

METHODS

A systematic search of randomized controlled trials (RCTs) published until May 2022 was performed using PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials. And a meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

RESULTS

A total of nine RCTs, including 2918 patients, met the eligibility criteria. The pooled overall incidences of all grade TRAEs, grade 3 or higher TRAEs and treatment-related death were 54.5% (95% confidence interval [CI]: 48.7%-60.2%, I²=75.55%), 12.8% (95% CI: 10.2%-15.7%, I²=51.61%) and 0.11% (95% CI: 0.00%-0.51%, I²=1.63%). Subgroup analyses showed that CTLA-4 inhibitors had a higher risk of any type of TRAEs, when compared with PD-1 and PD-L1 inhibitors. Meta-regression showed significant correlation between all grade TRAEs and proportion of female. Fatigue and diarrhoea were involved in common TRAEs.

CONCLUSIONS

Our study provides a comprehensive overview of ICIs-associated AEs in AG/GEJC. Immunotherapy did not have a significantly increased risk experiencing any type of TRAEs, and ICIs had a more manageable safety profile than chemotherapy. These findings provide important guidance to clinicians in counseling and management of patients with AG/GEJC.

Early gastric cancer: A challenge in Western countries

Early gastric cancer (EGC) is an invasive carcinoma involving only the stomach mucosa or submucosa, independently of lymph node status. EGC represents over 50% of cases in Japan and in South Korea, whereas it accounts only for approximately 20% of all newly diagnosed gastric cancers in Western countries. The main classification systems of EGC are the Vienna histopathologic classification and the Paris endoscopic classification of polypoid and non-polypoid lesions. A careful endoscopic assessment is fundamental to establish the best treatment of EGC. Generally, EGCs are curable if the lesion is completely removed by endoscopic resection or surgery. Some types of EGC can be resected endoscopically; for others the most appropriate treatment is surgical resection and D2 lymphadenectomy, especially in Western countries. The favorable oncological prognosis, the extended lymphadenectomy and the reconstruction of the intestinal continuity that excludes the duodenum make the prophylactic cholecystectomy mandatory to avoid the onset of biliary complications.

Meningeal carcinomatosis following a curative endoscopic submucosal dissection of early gastric cancer: a case report

Meningeal carcinomatosis (MC) is reported to occur in 4%-15% of patients with solid tumors. MC is not commonly associated with gastric carcinoma and is extremely rare in patients with early gastric cancer (EGC). MC derived from EGC after curative endoscopic submucosal dissection (ESD) has not been reported before. We present a rare case of a 49-year-old patient who developed MC after curative ESD of EGC. The cancer was an ulcerated lesion approximately 1.0 cm in diameter in endoscopic appearance in the minor curvature of the gastric antrum. The pathological examination after ESD indicated high-grade intraepithelial neoplasia (1.3 × 2.1 cm in size) with localized moderately differentiated adenocarcinoma (0-IIc in tumor stage, intestinal type in Lauren classification), which was confined to the mucosal layer with an intact submucosal layer and muscularis propria. The lesion was removed entirely by curative dissection without vertical and horizontal resection margins involvement in pathology. Two months after ESD, the patient was readmitted for severe headache and vomiting. Cytological examination of the cerebrospinal fluid found malignant tumor cells, which were considered by pathologists to have metastasized from the stomach, further confirming MC derived from EGC. The patient's condition deteriorated dramatically, which prevented him from receiving further therapies, such as chemotherapy, and he died 3 days after the diagnosis of MC. In conclusion, EGC can cause MC, even after curative ESD. New neurological manifestations in patients with EGC can alert physicians to a diagnosis of MC, and more attention needs to be paid to evaluating the nervous system and establishing diagnostic and therapeutic strategies as soon as possible.

Quantifying early gastric cancer in Australia: What is the opportunity for gastric endoscopic submucosal dissection?

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is the recommended treatment for early gastric cancer (EGC). However, there are challenges in attaining expertise in ESD in countries where the incidence of gastric cancer and proportion diagnosed at an early stage of disease are relatively low. This study aims to establish the proportion of gastric cancer meeting histological criteria for EGC, which may be suitable for ESD, in a Western population.

METHODS

Gastric cancers reported to the Victorian Cancer Registry between January 2011 and December 2016 were analyzed. EGC was defined as tumor confined to mucosa (T1a) or submucosa (T1b). Histology reports were analyzed using Japanese and European guidelines to identify potential ESD candidates. Criteria for extended ESD were based on grade of differentiation, tumor depth, lymphovascular and perineural invasion, and ulceration.

RESULTS

Twenty percent of 1217 gastric cancers was EGC (237 cases), with detailed histopathology reports suitable for evaluating ESD criteria recorded in 182 cases. Standard and extended ESD criteria were met in 46% (84/182) and 75% (132/182), respectively. Actual treatment of the 237 EGC was endoscopic in 14% (n = 33) and surgery in 86% (n = 204). Endoscopically treated EGCs were more likely to be stage T1a and located in the proximal stomach.

CONCLUSIONS

EGCs represented 20% of reported gastric adenocarcinomas with the majority fulfilling criteria for ESD. ESD should be considered in the management algorithm and discussed at tumor board meetings involving interventional endoscopists. To increase utilization of ESD, systems need to be implemented to improve training, accreditation, and access to ESD.

Elevated SYNC Expression Is Associated with Gastric Tumorigenesis and Infiltration of M2-Polarized Macrophages in the Gastric Tumor Immune Microenvironment

Aims: To assess the expression and epigenetic regulation of Syncoilin, intermediate filament protein (SYNC) in gastric cancer tissues, and to determine its associations with clinicopathological features; immune infiltration of macrophages in tumors; and patient survival. Materials and Methods: Clinicopathological features, expression profiles, and methylation data of the SYNC gene were obtained from multi-institutional real-world public datasets. A total of 1601 samples from patients with gastric cancer were examined. The associations between clinicopathological features and SYNC expression levels were assessed by the chi-square test; survival was assessed using the Kaplan-Meier analysis. The infiltration levels of M1, 2-polarized tumor-associated macrophages (TAMs) in a gastric tumor immune microenvironment were quantified using deconvolution, and the correlation between SYNC expression level and M1, 2-polarized macrophages' infiltration was examined using the Pearson correlation test. SYNC gene methylation data were analyzed to investigate epigenetic control of its expression. Results: SYNC expression was elevated in gastric cancer tissues (p < 0.01), and was associated with a poorer overall survival (p < 0.01) and poorer postprogression survival (p = 0.01). Higher SYNC levels were significantly associated with more aggressive clinicopathological features in gastric cancer patients (p < 0.05). SYNC was also associated with the infiltration of M2-polarized TAMs in the gastric tumor immune microenvironment (p < 0.001). Hypomethylation was shown to be associated with SYNC's upregulation (p < 0.05). Conclusion: SYNC is highly expressed in gastric cancer tissues and has the potential to be a therapeutic target and to serve as a prognostic marker.

SNHG10 Promotes Cell Proliferation and Migration in Gastric Cancer by Targeting miR-495-3p/CTNNB1 Axis

BACKGROUND

Long non-coding RNAs have been acknowledged as the crucial regulators in the progression of human cancers, including gastric cancer (GC). Small nucleolar RNA host gene 10 (SNHG10) has been identified as an oncogene in several cancer types. Nonetheless, it is unclear whether SNHG10 exerts functions in GC cells.

AIMS

The aims of the current study were to explore the function and underlying mechanism of SNHG10 in GC.

METHODS

The expression levels of SNHG10, miR-495-3p and catenin beta 1 (CTNNB1) were detected by RT-qPCR. Loss-of-function assays, including CCK-8, colony formation assay, flow cytometry analysis and transwell assays, were conducted to verify the effect of SHNG10 on the proliferation, apoptosis, migration and invasion of GC cells. Mechanism experiments were performed to identify the downstream molecular mechanism of SNHG10.

RESULTS

SNHG10 was expressed at a high level in GC cells. Knockdown of SNHG10 inhibited the proliferation, migration and invasion of GC cells. Silencing of SNHG10 led to the downregulation of core factors of WNT signaling pathway. Knockdown of SNHG10 could decline the expression of CTNNB1 through sequestering miR-495-3p.

CONCLUSIONS

SNHG10 promotes the procession of GC through targeting miR-495-3p/CTNNB1 and activating WNT signaling pathway.

Laparoscopic Gastrectomy with D2 Lymphadenectomy for pT1a Adenocarcinoma: Case Report and Literature Review

Gastric cancer is one of the most common malignancies, associated with a high mortality and morbidity rate, especially in the elderly, the fourth leading cause of cancer mortality in Europe. Although the rate of diagnosis has declined in recent years, the prognosis of the disease and the mortality rate is still quite high. Laparoscopic surgery, accompanied by lymphadenectomy, is a curative method of treatment, used more and more frequently, especially in Eastern countries, both in the incipient disease and in advanced stages of the disease, which has many advantages over classical surgery.

We report the case of an 86-year-old man, who presented for marked physical asthenia, weight loss and severe anemia, in whom we performed laparoscopic distal radical gastrectomy with D2 lymphadenectomy and Roux-en-Y reconstruction. Histopathological examination established the diagnosis of low-grade / well-differentiated tubular adenocarcinoma G1 (WHO) / intestinal carcinoma (Lauren), with invasion in the lamina propria, developed on an intestinal-type adenoma. 21 lymph nodes were taken without tumor invasion.

This case highlights the complexity of laparoscopic intervention, with the proven advantages for the patient, like reduced surgical trauma and pain, with the decrease of postoperative complications, but also the difficulty of the surgical technique which requires advanced laparoscopic skills. Thus, in addition to its proven efficacy in cases of early gastric cancer, the technique can be extended to advanced malignancies, without affecting the oncological safety limit.

Early Gastric Cancer: identification of molecular markers able to distinguish submucosa-penetrating lesions with different prognosis

BACKGROUND

Early Gastric Cancer (EGC) reaches 25% of the gastric cancers surgically treated in some areas of Northeastern Italy and is usually characterized by a good prognosis. However, among EGCs classified according to Kodama's criteria, Pen A subgroup is characterized by extensive submucosal invasion, lymph node metastases and worse prognosis, whereas Pen B subgroup by better prognosis. The aim of the study was to characterize the differences between Pen A, Pen B and locally advanced gastric cancer (T3N0) in order to identify biomarkers involved in aggressiveness and clinical outcome.

METHODS

We selected 33 Pen A, 34 Pen B and 20 T3N0 tumors and performed immunohistochemistry of mucins, copy number variation analysis of a gene panel, microsatellite instability (MSI), TP53 mutation and loss of heterozygosity (LOH) analyses.

RESULTS

Pen A subgroup was characterized by MUC6 overexpression (p = 0.021). Otherwise, the Pen B subgroup was significantly associated with the amplification of GATA6 gene (p = 0.002). The higher percentage of MSI tumors was observed in T3N0 group (p = 0.002), but no significant differences between EGC types were found. Finally, TP53 gene analysis showed that 32.8% of Pen tumors have a mutation in exons 5-8 and 50.0% presented LOH. Co-occurrence of TP53 mutation and LOH mainly characterized Pen A tumors (p = 0.022).

CONCLUSIONS

Our analyses revealed that clinico-pathological parameters, microsatellite status and frequency of TP53 mutations do not seem to distinguish Pen subgroups. Conversely, the amplification of GATA6 was associated with Pen B, as well as the overexpression of MUC6 and the TP53mut/LOH significantly characterized Pen A.

Gastric cancer: a comprehensive review of current and future treatment strategies

Gastric cancer remains a major unmet clinical problem with over 1 million new cases worldwide. It is the fourth most commonly occurring cancer in men and the seventh most commonly occurring cancer in women. A major fraction of gastric cancer has been linked to variety of pathogenic infections including but not limited to Helicobacter pylori (H. pylori) or Epstein Barr virus (EBV). Strategies are being pursued to prevent gastric cancer development such as H. pylori eradication, which has helped to prevent significant proportion of gastric cancer. Today, treatments have helped to manage this disease and the 5-year survival for stage IA and IB tumors treated with surgery are between 60 and 80%. However, patients with stage III tumors undergoing surgery have a dismal 5-year survival rate between 18 and 50% depending on the dataset. These figures indicate the need for more effective molecularly driven treatment strategies. This review discusses the molecular profile of gastric tumors, the success, and challenges with available therapeutic targets along with newer biomarkers and emerging targets.

High ELK3 expression is associated with the VEGF-C/VEGFR-3 axis and gastric tumorigenesis and enhances infiltration of M2 macrophages

Aim: To assess the expression and effect of ELK3 in gastric cancer, along with its associations with the VEGF-C/VEGFR-3 axis, IC₅₀ of the VEGFR-3 inhibitor axitinib and immune infiltration of M2-polarized macrophages in gastric cancer, and to analyze the possible epigenetic regulation mechanism. Materials & methods: Expression profiles and methylation data from 1645 samples were obtained and examined from multi-institutional public datasets. The associations were assessed by multiple analysis methods. Results: Elevated ELK3 is associated with the VEGF-C/VEGFR-3 axis and tumorigenesis, reduces the effect of axitinib in vitro, enhances immune infiltration of M2 macrophages and affects clinical outcomes. Hypomethylation contributes to the upregulation of ELK3 in gastric cancer. Conclusions: ELK3 is a potential therapeutic target which reduces the effect of axitinib and enhances infiltration of M2-polarized macrophages.

Large population-based study using the SEER database: is endoscopic resection appropriate for early gastric cancer patients in the United States?

AIM

To investigate whether endoscopic treatment is applicable to American patients and explores the predictors of lymph node metastasis (LNM) in early gastric cancer (EGC).

METHODS

Patients with EGC confined to either mucosa (T1a, n = 1799) and submucosa (T1b, n = 1689) were identified from the Surveillance, Epidemiology, and End Result database. Multivariate logistic regression, Kaplan-Meier method, and univariate/multivariate Cox regression were used to assess the correlation between invasion depth and LNM or prognosis. A nomogram for predicting LNM was constructed and internally validated.

RESULTS

EGC limited to T1a exhibited a 2.4% incidence of LNM, which increased to 11.1% when the depth invaded T1b.LNM was present at 1.4%, 5.2%, and 5.0% for sizes ≤2, 2-5, and >5cm of low-grade T1a EGC, respectively, (p = .019) and at 4.8%, 12.4%, and 28.6% of T1b EGC, respectively (p  < .001).The multivariate logistic model revealed that older age, T1b invasion, larger tumor size, and high-grade lesions were associated with a higher risk of LNM. Moreover, the T1a EGC patients had better cancer-specific survival (OS) and overall survival(CSS) compared with the T1b EGC patients (5-year OS: 77.2% versus 67.4%, p < .001; 5-year CSS: 90.6% versus 81.4%, p < .001). The discrimination of the prediction model was 0.745.

CONCLUSIONS

Endoscopic treatment may only be suitable for patients in the US population who have low-grade T1a lesions of less than 2 cm in size. Patients with T1a lesions of greater than 2 cm in size, lesions with high-grade, and all T1b lesions may benefit from radical surgical resection with lymphadenectomy.

The impact of endoscopic submucosal dissection for gastric adenocarcinomas in the United States

BACKGROUND AND AIMS

Recent studies show promise for endoscopic submucosal dissection (ESD) in the US, but do not identify the potential impact of ESD among newly diagnosed gastric cancers. We utilize the Veterans Health Administration to identify cancers suitable for ESD, to define the role of ESD in the US.

METHODS

Retrospective cohort study using the Veterans Affairs Central Cancer Registry to identify patients with gastric cancer who underwent surgical resection from 1995-2018. TNM stage was used to categorize those who would meet absolute vs expanded indications for ESD. Primary outcome was lymph node status. Secondary analysis was performed with death as outcome.

RESULTS

Of 12,584 primary gastric cancers, 4,735 (37.6%) were non-metastatic gastric adenocarcinomas. Median age at diagnosis was 70.3 years, 4,676 (98.8%) male. 2,306 (48.7%) underwent surgical resection, of which 636 (27.6%) were T1 lesions or cancer in situ. Of these, 44 (6.9%) met absolute indications for resection, 99 (15.6%) met established expanded criteria, and 98 (15.4%) may meet expanded criteria. Half of all tumors in each group were proximal in location.Rate of lymph node positivity was: 4.5%; 95% CI:0.5-15.5% in absolute group; 8.1%; 95% CI:3.6-15.3% in expanded group; 13.3%; 95% CI:7.3-21.6 in those potentially meeting expanded criteria. Lymph nodes positivity was associated with death (HR 1.49; 95% CI:1.36-1.62, p<0.001).

CONCLUSIONS

Less than 10% of T1 or in situ cancers meet absolute criteria for ESD. Those that meet expanded criteria had higher risk for lymph node metastases, particularly proximal tumors. Future studies should evaluate the safety of ESD in proximal gastric tumors.

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.

Consensus statement of the Hellenic and Cypriot Gastric Cancer Study Group on the diagnosis, staging and management of gastric cancer

Gastric Cancer epidemics have changed over recent decades, declining in incidence, shifting from distal to proximal location, transforming from intestinal to diffuse histology. Novel chemotherapeutic agents combined with modern surgical operations hardly changed overall disease related survival. This may be attributed to a substantial inherent geographical variation of disease genetics, but also to a failure to standardize and implement treatment protocols in clinical practice. To overcome these drawbacks in Greece and Cyprus, a Gastric Cancer Study Group under the auspices of the Hellenic Society of Medical Oncology (HeSMO) and Gastrointestinal Cancer Study Group (GIC-SG) merged their efforts to produce a consensus considering ethnic parameters of healthcare system and the international proposals as well. Utilizing structured meetings of experts, a consensus was reached. To achieve further consensus, statements were subjected to the Delphi methodology by invited multidisciplinary national and international experts. Sentences were considered of high or low consensus if they were voted by ≥ 80%, or < 80%, respectively; those obtaining a low consensus level after both voting rounds were rejected. Forty-five statements were developed and voted by 71 experts. The median rate of abstention per statement was 9.9% (range: 0-53.5%). At the end of the process, one statement was rejected, another revised, and all the remaining achieved a high consensus. Forty-four recommendations covering all aspects of the management of gastric cancer and concise treatment algorithms are proposed by the Hellenic and Cypriot Gastric Cancer Study Group. The importance of centralization, care by a multidisciplinary team, adherence to guidelines, and individualization are emphasized.

Appearance of cutaneous melanoma and subcutaneous metastases in metastatic gastric carcinoma undergoing chemotherapy with oral 5-fluorouracil prodrug

Metastatic skin lesions of gastric cancers usually appear as nonspecific, firm, and hyperpigmented nodules. However, they occasionally present as unusual skin manifestations that mimic other skin disorders. We describe a case of multiple cutaneous metastases from gastric cancer resembling sebaceous cysts with a synchronous melanoma, in a patient after fluoropyrimidine-based systemic chemotherapy. Melanoma occurring as a second cancer has been recognized in patients having undergone previous chemotherapy or radiation for another cancer. We can assume that the capecitabine-based chemotherapy may have played a role in the development of the melanocytic neoplasm. Our observation adds extra evidence to the link between fluoropyrimidine-based immunosuppression and the induction of melanocytes' proliferation and transformation. For these reasons, it is advisable to require dermatological checkups for patients undergoing chemotherapy treatments in order to identify suspicious melanocytic lesions as soon as possible.

Differential effects, on oncogenic pathway signalling, by derivatives of the HNF4 α inhibitor BI6015

Background

Gastric cancer (GC) is a highly heterogeneous disease with few “targeted” therapeutic options. Previously, we demonstrated involvement of the transcription factor HNF4α in human GC tumours, and the developmental signal mediator, WNT5A, as a prognostic GC biomarker. One previously developed HNF4α antagonist, BI6015, while not advancing beyond preclinical stages, remains useful for studying GC.

Methods

Here, we characterised the antineoplastic signalling activity of derivatives of BI6015, including transfer of the nitro group from the para position, relative to a methyl group on its benzene ring, to the ortho- and meta positions. We assessed binding efficacy, through surface plasmon resonance and docking studies, while biologic activity was assessed by antimitogenic efficacy against a panel of GC cell lines, and dysregulated transcriptomes, followed by pathway and subpathway analysis.

Results

The para derivative of BI6105 was found substantially more growth inhibitory, and effective, in downregulating numerous oncogenic signal pathways, including the embryonic cascade WNT. The ortho and meta derivatives, however, failed to downregulate WNT or other embryonic signalling pathways, unable to suppress GC growth.

Conclusion

Straightforward strategies, employing bioinformatics analyses, to facilitate the effective design and development of “druggable” transcription factor inhibitors, are useful for targeting specific oncogenic signalling pathways, in GC and other cancers.

S-1 combined with paclitaxel may benefit advanced gastric cancer: Evidence from a systematic review and meta-analysis

BACKGROUND

Gastric cancer, as one of the increasingly common malignancies, has experienced high morbidity throughout many countries at present. Currently, chemotherapy regimen with more efficacy and safety for advanced gastric cancer (AGC) is needed. We aimed to assess the clinical efficacy and safety of S-1 combined with paclitaxel (PTX) for AGC by performing a systematic review and meta-analysis of the published studies.

METHOD

All published randomized controlled trials (RCTs) of S-1 combined with PTX for AGC were searched. Studies that included patients with locally advanced or metastases' gastric cancers were included. We searched the databases included Cochrane Library of Clinical Comparative Trials, MEDLINE, Embase, American Society of Clinical Oncology meeting abstracts and China National Knowledge Internet (CNKI) from 2000 to 2018. We searched the database up to January 2018. The first endpoint was overall survival (OS). Other endpoints were progression-free survival (PFS), objective response rate (ORR) and disease control rate (DCR). Safety analyses were also performed.

RESULTS

A total of 7 trials (including 1407 patients, 711 patients in intervention group and 696 patients in control group) were included in the present analysis. S-1 combined with PTX significantly improved the OS [HR = 0.78, 95% CI: 0.60-0.97, P = 0.000],PFS [HR = 0.70, 95% CI: 0.55-0.85, P = 0.000], ORR [RR = 1.30, 95%CI: 1.05-1.60, P = 0.017] and DCR [RR = 1.15, 95%CI: 1.04-1.27, P = 0.008] of patients with AGC. The grade 3 or 4 haematological and non-hematologic toxicities were anemia [RR = 1.71, 95% CI: 1.04-2.79, P = 0.03], neutropenia [RR = 1.65, 95% CI: 1.32-2.06, P < 0.0001] and anorexia [RR = 1.66, 95% CI: 1.05-2.64, P = 0.03] respectively.

CONCLUSION

S-1 combined with PTX may be a good choice for patients with AGC. S-1 plus PTX experienced more efficacy and safety when compared with S-1 alone or S-1 plus other drugs.

A Comparison by Meta-Analysis of Papillary Early Gastric Carcinoma to Its Tubular Counterpart for the Risk of Lymph Node Metastasis and Submucosal Invasion

BACKGROUND AND AIM

At present, the decision to perform endoscopic resection for treating either papillary early gastric cancer (EGC) or tubular EGC is made according to identical criteria. However, there is controversy in the literature whether the risk of lymph node metastasis (LNM) and submucosal invasion for both disease modalities is equal, and this prompts investigation to clarify this issue.

METHODS

The PubMed and Web of Science databases were searched for relevant studies published up to January 2017. Data were extracted, and the pooled odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated using a random-effects or a fixed-effects model, according to heterogeneity.

RESULTS

A total of 13 studies were included in this analysis. Papillary EGC had a significantly higher LNM risk (OR, 1.97; 95% CI, 1.38-2.82) and submucosal invasion risk (OR, 1.44; 95% CI, 1.08-1.93), compared with tubular EGC. Stratified by geographic location, a significantly increased risk of LNM (OR, 2.28; 95% CI, 1.57-3.30) and submucosal invasion (OR, 1.52; 95% CI, 1.13-2.04) associated with papillary EGC was found in Asian studies. In addition, papillary EGC exhibited significantly more frequent elevated/flat growth patterns (OR, 7.54, 95% CI, 4.76-11.96).

CONCLUSIONS

Our study identifies an increased risk for submucosal invasion and LNM in papillary EGC compared with tubular EGC, indicating that papillary EGC requires more careful clinical management compared with tubular EGC.

Dual Energy Spectral CT Imaging in the assessment of Gastric Cancer and cell proliferation: A Preliminary Study

Gastric cancer is one of the main diseases leading to cancer-related death. The recently introduced dual-energy spectral CT (DEsCT), allows to obtain many quantitative measurements from iodine-based material decomposition (MD) images, which contribute to improve the accuracy of staging of GC comparing to multidetector spiral CT. And Ki-67 is a well-recognized nuclear antigen-specific biomarker reflecting cellular proliferation for estimating growth fractions of various tumor types. In the present study we analyzed the features of quantitative measurements (the curve slope (λ_HU), IC, normalized iodine concentrations (NIC)) obtained from DEsCT and levels of Ki-67 protein expression. We demonstrated that the values between advanced gastric cancer (AGC) and early gastric cancer (EGC) were significantly different both in venous phase (VP) and delayed phase (DP). The values of different level of Ki-67 expression grade were significantly different both in VP and DP. The rank correlation analysis between Ki-67 grade and IC, NIC and λ_HU values showed significantly positive correlation in VP and DP. These results suggested that quantitative parameters (IC, NIC and λ_HU) in dual-energy CT imaging can be used to differentiate EGC from AGC, and have significantly positive correlation with Ki-67 antigen expression levels in gastric cancer for indicating tumor cellular proliferation.

Role of CA19-9 in the prognostic evaluation of SOX neoadjuvant chemotherapy for gastric cancer

OBJECTIVE

Neoadjuvant chemotherapy refers to systemic chemotherapy applied before local surgery or radiotherapy for malignant tumors. The level of certain tumor markers is an important indicator for assessing the efficacy of neoadjuvant chemotherapy. This study aimed to investigate the effect of serum CA19-9 levels on subsequent neoadjuvant chemotherapy in the treatment of gastric adenocarcinoma.

METHODS

We collected 86 advanced gastric adenocarcinoma patients from January 2016 to May 2018. Patients received at least 2 cycles neoadjuvant chemotherapy with SOX (Oxaliplatin, S-1) before surgery. Effective chemotherapy was defined as producing CR or PR andineffective was defined as SD or PD. We analyze the role of serum CA19-9 level in predicting the effectiveness of neoadjuvant chemotherapy in patients with advanced gastric cancer.

RESULTS

In total 86 patients, 28 patients had abnormal and 58 patients had normal serum CA19-9 levels. The positivity rate of pretreatment serum CA19-9 was higher when PR or CR was achieved (P=0.0005***). The area under the ROC curve (AUC) for CA19-9 levels was 0.720 (95% CI 0.610-0.829) (P=0.001**).

CONCLUSIONS

Measurements of CA19-9 may be helpful in monitoring the efficacy of neoadjuvant chemotherapy in the treatment of patients with advanced gastric cancer and also may be able to effectively predict this effect, thereby reducing unnecessary chemotherapy.

Regulatory T-cell density and cytotoxic T lymphocyte density are associated with complete response to neoadjuvant paclitaxel and carboplatin chemoradiotherapy in gastric cancer

Regulatory T-cell density and cytotoxic T lymphocyte density are crucial in regulating antitumor immune responses. Tumor infiltration has marked therapeutic effects in gastric carcinoma, and there is evidence that chemoradiotherapy (CRT) exhibits an immune-mediated component. In the present study, the density of CD4⁺ and CD8⁺ cells were evaluated in post-CRT surgical samples from 68 patients with gastric cancer using immunohistochemistry. The associations between T-cell density, cytotoxic T lymphocyte density and clinical survival rate were also analyzed. Cytotoxic T lymphocyte density was associated with gastric carcinoma regression grade and regulatory T-cell density was also associated with gastric carcinoma regression grade. Of the patients who had a pathologic complete response, 84 and 76% were found to have a high CD3⁺ and CD4⁺ cell density, which was significantly different to patients who had a low CD3⁺ and CD4⁺ cell density. High cytotoxic T lymphocyte density was also associated with improved survival rates of patients with gastric cancer. In conclusion, these outcomes indicated that regulatory T-cell density and cytotoxic T lymphocyte density in the tumor microenvironment were associated with the response to neoadjuvant CRT and may represent a therapeutic target for gastric cancer.

Safety of expanded criteria for endoscopic resection of early gastric cancer in a Western cohort

Background

Endoscopic resection is widely accepted treatment option for early gastric cancer if tumors meet the standard or expanded indications. However, the safety of expanded criteria is still under investigation. Furthermore, discussion, if any additional treatment is necessary for patients who underwent endoscopic resection but exceeded expanded criteria, is rising. This study aimed to evaluate the safety of extended indications for endoscopic resection of early gastric cancer in a Western cohort. Also, we aimed to analyze the lymph node metastasis rate in tumors which exceeds the extended criteria.

Methods

Two hundred eighteen patients who underwent surgery for early gastric cancer at National Cancer Institute, Vilnius, Lithuania between 2005 and 2015 were identified from a prospective database. Lymph node status was examined in 197 patients who met or exceeded extended indications for endoscopic resection.

Results

Lymph node metastasis was detected in 1.7% of cancers who met extended indications and in 30.2% of cancers who exceeded expanded indications. Lymphovascular invasion and deeper tumor invasion is associated with lymph node metastasis in cancers exceeding expanded indications.

Conclusions

Expanded criteria for endoscopic resection of early gastric cancer in Western settings is not entirely safe because these tumors carry the risk of lymph node metastasis.

Selective survival advantage associated with primary tumor resection for metastatic gastric cancer in a Western population

BACKGROUND

The prognosis of metastatic gastric cancer (GC) remains dismal, with a median survival of 10 months. Historically, primary tumor resection was not thought to confer any survival benefit. Although high-level data exist guiding treatment of metastatic GC for patients in the East, no such data exist for Western patients despite inherent ethnic differences in GC biology.

METHODS

The 2006-2012 National Cancer Database was queried for adult patients with metastatic gastric adenocarcinoma. Patients were classified into those who underwent primary tumor resection and chemotherapy (PTRaC) and those who received chemotherapy only. Groups were propensity score matched, and survival was compared using advanced statistical modeling.

RESULTS

A total of 7026 patients met the inclusion criteria: 6129 (87%) patients were treated with chemotherapy alone and 897 (13%) patients were treated with PTRaC. After multivariable adjustment, patients who underwent PTRaC had a significantly better overall survival (OS) than patients who received systemic therapy only (HR, 0.60; 95% CI, 0.56-0.64; p < 0.001). Following full bipartite propensity score-adjusted analysis, 2-year OS for patients who received chemotherapy only was 12.6% (95% CI, 11.7-13.5%), whereas it was 34.2% (95% CI, 31.3-37.5%) for patients who underwent PTRaC (HR for resection: 0.52; 95% CI, 0.47-0.57; p < 0.001).

CONCLUSION

Our data suggest that there exists a subset of patients with metastatic GC for which PTRaC may improve OS. As significant uncertainty still remains, our results support the need for further prospective trials investigating the influence of palliative gastrectomy on survival among Western patients.

Adoption of evidence-based novel therapies in the treatment of gastric cancer: A national observational study

BACKGROUND

The adoption of novel and effective gastric cancer therapies into general clinical practice has crucial implications for patient outcomes. The current study explored trends in treatment use and overall survival in patients with gastric cancer in the United States.

METHODS

Patients with adenocarcinoma of the gastric cardia and noncardia were identified in the National Cancer Data Base between 2006 and 2014. Tumor stages were divided into early (IA), locally advanced (IB-IIIC), and metastatic (IV) stage. Treatment use was examined according to tumor stage and location. Time trend analyses of treatment use and overall survival were conducted.

RESULTS

A total of 89,098 patients with gastric adenocarcinoma were identified. In those with early-stage cancer, endoscopic treatment increased over time in patients with cardia and noncardia disease. In patients with locally advanced cardia disease, preoperative therapy use increased over time (2013-2014 [vs 2006-2008]: odds ratio [OR], 3.09; 95% confidence interval [95% CI], 2.80-3.41). In patients with locally advanced noncardia disease, the use of preoperative therapy also increased (2013-2014: OR, 3.32; 95% CI, 2.88-3.82) as did the use of perioperative therapy (2013-2014: OR, 4.21; 95% CI, 3.52-5.03) in lieu of postoperative treatment (2013-2014: OR, 0.66; 95% CI, 0.60-0.71). In patients with metastatic disease, approximately 34% of patients with cardia and 40% of patients with noncardia cancer did not receive treatment. Stage-specific and location-specific overall survival was found to improve over the study period.

CONCLUSIONS

Practice patterns for the treatment of gastric cancer in the United States reflect the increased adoption of evidence-based therapies, including endoscopic resection of early-stage cancer and preoperative therapy for patients with locally advanced disease. Treatment for metastatic disease remains markedly underused. Cancer 2018;124:1122-31. © 2017 American Cancer Society.

The Role of Epigenetic Regulation in Epstein-Barr Virus-Associated Gastric Cancer

The Epstein–Barr virus (EBV) is detected in about 10% of gastric carcinoma cases throughout the world. In EBV-associated gastric carcinoma (EBVaGC), all tumor cells harbor the clonal EBV genome. The expression of latent EBV genes is strictly regulated through the methylation of EBV DNA. The methylation of viral DNA regulates the type of EBV latency, and methylation of the tumor suppressor genes is a key abnormality in EBVaGC. The methylation frequencies of several tumor suppressor genes and cell adhesion molecules are significantly higher in EBVaGC than in control cases. EBV-derived microRNAs repress translation from viral and host mRNAs. EBV regulates the expression of non-coding RNA in gastric carcinoma. With regard to the clinical application of demethylating agents against EBVaGC, we investigated the effects of decitabine against the EBVaGC cell lines. Decitabine inhibited the cell growth of EBVaGC cells. The promoter regions of p73 and Runt-related transcription factor 3(RUNX3) were demethylated, and their expression was upregulated by the treatment. We review the role of epigenetic regulation in the development and maintenance of EBVaGC and discuss the therapeutic application of DNA demethylating agents for EBVaGC.

Botulinum Toxin Injection for the Treatment of Delayed Gastric Emptying Following Pylorus-Preserving Gastrectomy: an Initial Experience

Purpose

To report our experience of endoscopic botulinum toxin injection in patients who experienced severe delayed gastric emptying after pylorus-preserving gastrectomy (PPG).

Materials and Methods

We reviewed the medical records of 6 patients who received the botulinum toxin injection. They presented with severe delayed gastric emptying in the early postoperative period. Endoscopic botulinum toxin was administered as 4 injections of 25−50 IU into each of the 4 quadrants of the prepyloric area.

Results

All botulinum toxin injections were successful without any complications, enabling 5 patients to tolerate soft solid diets and one to tolerate a soft fluid diet within 10 days. The endoscopic criteria of 4 patients improved. Symptom recurrence caused 2 patients to undergo repeat injections that were successful. The median follow-up period was 27 months, and all patients could ingest normal regular diets at the last follow-up.

Conclusions

Endoscopic botulinum toxin injection is a feasible treatment option for early delayed gastric emptying after PPG.

Decitabine inhibits tumor cell proliferation and up-regulates e-cadherin expression in Epstein-Barr virus-associated gastric cancer

The present study investigated the effect of a DNA demethylating agent, decitabine, against Epstein-Barr virus-associated gastric cancer (EBVaGC). Decitabine inhibited cell growth and induced G2/M arrest and apoptosis in EBVaGC cell lines. The expression of E-cadherin was up-regulated and cell motility was significantly inhibited in the cells treated with decitabine. The promoter regions of p73 and RUNX3 were demethylated, and their expression was up-regulated by decitabine. They enhanced the transcription of p21, which induced G2/M arrest and apoptosis through down-regulation of c-Myc. Decitabine also induced the expression of BZLF1 in SNU719. Induction of EBV lytic infection was an alternative way to cause apoptosis of the host cells. This study is the first report to reveal the effectiveness of a demethylating agent in inhibiting tumor cell proliferation and up-regulation of E-cadherin in EBVaGC. J. Med. Virol. 89:508-517, 2017. © 2016 Wiley Periodicals, Inc.

Expression of microtubule-associated protein TPX2 in human gastric carcinoma and its prognostic significance

BACKGROUND

The molecular mechanisms underlying the development and progression of gastric carcinoma remain poorly understood. The main objective of this study was to investigate the expression level of targeting protein for Xenopus kinesin-like protein 2 (TPX2) and its clinical significance in human gastric carcinoma.

METHODS

Real-time quantitative polymerase chain reaction (RT-PCR) and western blotting were used to determine the mRNA and protein levels of TPX2 in 20 paired gastric carcinoma tissues and the adjacent normal tissues, and the expression of TPX2 protein in 106 specimens of a gastric carcinoma tissue microarray was determined by immunohistochemistry. The associations of TPX2 expression with the clinicopathological features were analyzed, and the prognosis of gastric carcinoma patients was evaluated.

RESULTS

The results showed that the expression of TPX2 mRNA was significantly higher in gastric carcinoma than in the adjacent normal tissues in 20 paired samples. Western blotting analysis revealed that TPX2 protein was differentially increased in 17 of 20 specimens from primary human gastric carcinoma tissues compared with those from adjacent non-tumor tissues. Immunohistochemical staining showed that TPX2 over-expression was significantly associated with advanced age (P = 0.001) and tumor T stage (P = 0.003). In addition, TPX2 was an independent prognostic factor for overall survival (OS) in the multivariate analysis [hazard ratio (HR) 0.001; 95 % confidence interval (CI) 2.626-7.198; P = 0.001].

CONCLUSIONS

TPX2 is up-regulated in gastric carcinoma and is associated with old age and tumor T stage. TPX2 may serve as a good prognostic indicator in patients with gastric carcinoma.

Should every region use the same gastric cancer scanning and treatment approaches? let's reconsider: a northeastern turkey example

Background

The rate for upper gastrointestinal (UGI) cancers, and especially the rate for gastric cancer, varies from country to country and from region to region within country. In Turkey, the incidence of gastric cancer varies widely among regions due to the diverse cultures and accompanying food habits of the population. This study aimed to determine the endoscopic frequency of esophageal and gastric cancers and the usefulness of alarm symptoms in diagnosing gastric cancer in subjects undergoing endoscopy in northeastern Turkey.

Methods

This retrospective study was based on hospital records, reviewing the records of patients who had underdone esophago-gastro-duodenal (EGD) video endoscopy at two general hospitals in Erzurum. From July 2010 to January 2013, 25,037 patients from Erzurum underwent EGD procedures under either intravenous sedation or local anesthesia. Classifications of UGI cancer, based on location of the tumor, were defined as esophageal, cardia, cardia and fundus or corpus or all of these, corpus, corpus and antrum, and antrum. Metastasis was studied in 659 patients diagnosed with cancer.

Results

Throughout the study, 1,007 biopsy samples were reported as malignant tumors (719 gastric, 276 esophageal, and 12 duodenal cancers). The study considered the gastric cancer population under age 46, which included 99 (13.8 %) patients. Among them, the distribution of UGI cancer by age was as follows: under age 26 years, 9 patients (0.9 %); age 26–35 years, 30 patients (3 %); and age 36–45 years, 60 patients (6 %). Overall, 298 patients (298/1007, 29.6 %) presented with localized disease, and 361 patients (35.9 %) had distant metastases at the time of diagnosis.

Conclusions

We determined that UGI cancer patients are observed more frequently in northeastern Turkey than in western Turkey, Europe, and the USA. We believe that alarm symptoms and endoscopic scanning programs require new, region-specific criteria to diagnose UGI cancers in this region. For the patient groups with these different characteristics, we believe that new scanning, follow-up, and treatment strategies are needed that take into consideration differences in the histopathology of the tumors, their localization, and the patients’ ages.

Trial registration

There is registration number. This study is “retrospective study”. This study is “retrospectively registered”.

Loss of OLFM4 promotes tumor migration through inducing interleukin-8 expression and predicts lymph node metastasis in early gastric cancer

Endoscopic surgery is increasingly used for early gastric cancer (EGC) treatment worldwide, and lymph node metastasis remains the most important risk factor for endoscopic surgery in EGC patients. Olfactomedin 4 (OLFM4) is mainly expressed in the digestive system and upregulated in several types of tumors. However, the role of OLFM4 in EGC has not been explored. We evaluated OLFM4 expression by immunohistochemical staining in 105 patients with EGC who underwent gastrectomy. The clinicopathological factors and OLFM4 expression were co-analyzed to predict lymph node metastasis in EGC. The metastatic mechanism of OLFM4 in gastric cancer was also investigated. We found that OLFM4 was upregulated in EGC tumor sections, and relatively low expression of OLFM4 was observed in patients with lymph node metastasis. OLFM4 expression as well as tumor size and differentiation were identified as independent factors, which could be co-analyzed to generate a better model for predicting lymph node metastasis in EGC patients. In vitro studies revealed that knockdown of OLFM4 promoted the migration of gastric cancer cells through activating the NF-κB/interleukin-8 axis. Negative correlation between OLFM4 and interleukin-8 expression was also observed in EGC tumor samples. Our study implies that OLFM4 expression is a potential predictor of lymph node metastasis in EGC, and combing OLFM4 with tumor size and differentiation could better stratify EGC patients with different risks of lymph node metastasis.

Early Gastric Cancer: Trends in Incidence, Management, and Survival in a Well-Defined French Population

BACKGROUND

Little is known about the epidemiology of early gastric cancer (EGC) in Western countries. The aim of this study was to analyze trends in the incidence, management, and survival of EGC in a well-defined population over a 30 year period.

METHODS

Data were obtained from the population-based cancer Registry of Burgundy (France). Incidence rates were calculated by sex, age, and 10 year period of diagnosis. Net survival rates were calculated and a multivariate relative survival analysis performed.

RESULTS

EGC represented 6.7 % of gastric cancer diagnosed between 1982 and 2011. Age-standardized incidence rates were higher in men (0.79/100,000) than in women (0.40/100,000). Between the periods 1982-1991 and 2002-2011, it decreased from 0.97 to 0.53 per 100,000 in men and from 0.44 to 0.30 per 100,000 in women. Overall, 19 % of the tumors were limited to the mucosa, 69 % to the submucosa, and 15 % invaded lymph nodes. Node invasion and male sex were the only significant prognostic factors. Five-year net survival was 50 % in node-positive patients and 85 % in node-negative patients (p < 0.001). In multivariate analysis, the relative risk of death in men compared to women was 2.3 and was 10.4 in patients with positive nodes compared to patients with negative nodes.

CONCLUSIONS

EGCs are rare in France. The prognosis is favorable, except for node-positive cancers, which may benefit from the recently developed adjuvant chemotherapy for gastric cancer.