Prophylactic effect of neoadjuvant chemotherapy in gastric cancer patients with postoperative complications

Prognostic Impact of Post-operative Infectious Complications in Gastric Cancer Patients Receiving Neoadjuvant Chemotherapy: Post Hoc Analysis of a Randomized Controlled Trial, JCOG0501

PURPOSE

Post-operative infectious complication (IC) is a well-known negative prognostic factor, while showing neoadjuvant chemotherapy (NAC) may cancel out the negative influence of IC. This analysis compared the clinical impacts of IC according to the presence or absence of NAC in gastric cancer patients enrolled in the phase III clinical trial (JCOG0501) which compared upfront surgery (arm A) and NAC followed by surgery (arm B) in type 4 and large type 3 gastric cancer.

METHODS

The subjects were 224 patients who underwent R0 resection out of 316 patients enrolled in JCOG0501. The prognoses of the patients with or without ICs in each arm were investigated by univariable and multivariable Cox regression analyses.

RESULTS

There were 21 (20.0%) IC occurrences in arm A and 15 (12.6%) in arm B. In arm A, the overall survival (OS) of patients with ICs was slightly worse than those without IC (3-year OS, 57.1% in patients with ICs, 79.8% in those without ICs; adjusted hazard ratio (95% confidence interval), 1.292 (0.655-2.546)). In arm B, patients with ICs showed a trend of better survival than those without ICs (3-year OS, 80.0% in patients with IC, 74.0% in those without IC; adjusted hazard ratio, 0.573 (0.226-1.456)).

CONCLUSION

This study could not indicate the negative prognostic influence of ICs in gastric cancer patients receiving NAC, which might be canceled by NAC. To build exact evidence, further investigation with prospective and large numbers of data might be expected.

Deep learning or radiomics based on CT for predicting the response of gastric cancer to neoadjuvant chemotherapy: a meta-analysis and systematic review

Background

Artificial intelligence (AI) models, clinical models (CM), and the integrated model (IM) are utilized to evaluate the response to neoadjuvant chemotherapy (NACT) in patients diagnosed with gastric cancer.

Objective

The objective is to identify the diagnostic test of the AI model and to compare the accuracy of AI, CM, and IM through a comprehensive summary of head-to-head comparative studies.

Methods

PubMed, Web of Science, Cochrane Library, and Embase were systematically searched until September 5, 2023, to compile English language studies without regional restrictions. The quality of the included studies was evaluated using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) criteria. Forest plots were utilized to illustrate the findings of diagnostic accuracy, while Hierarchical Summary Receiver Operating Characteristic curves were generated to estimate sensitivity (SEN) and specificity (SPE). Meta-regression was applied to analyze heterogeneity across the studies. To assess the presence of publication bias, Deeks' funnel plot and an asymmetry test were employed.

Results

A total of 9 studies, comprising 3313 patients, were included for the AI model, with 7 head-to-head comparative studies involving 2699 patients. Across the 9 studies, the pooled SEN for the AI model was 0.75 (95% confidence interval (CI): 0.66, 0.82), and SPE was 0.77 (95% CI: 0.69, 0.84). Meta-regression was conducted, revealing that the cut-off value, approach to predicting response, and gold standard might be sources of heterogeneity. In the head-to-head comparative studies, the pooled SEN for AI was 0.77 (95% CI: 0.69, 0.84) with SPE at 0.79 (95% CI: 0.70, 0.85). For CM, the pooled SEN was 0.67 (95% CI: 0.57, 0.77) with SPE at 0.59 (95% CI: 0.54, 0.64), while for IM, the pooled SEN was 0.83 (95% CI: 0.79, 0.86) with SPE at 0.69 (95% CI: 0.56, 0.79). Notably, there was no statistical difference, except that IM exhibited higher SEN than AI, while maintaining a similar level of SPE in pairwise comparisons. In the Receiver Operating Characteristic analysis subgroup, the CT-based Deep Learning (DL) subgroup, and the National Comprehensive Cancer Network (NCCN) guideline subgroup, the AI model exhibited higher SEN but lower SPE compared to the IM. Conversely, in the training cohort subgroup and the internal validation cohort subgroup, the AI model demonstrated lower SEN but higher SPE than the IM. The subgroup analysis underscored that factors such as the number of cohorts, cohort type, cut-off value, approach to predicting response, and choice of gold standard could impact the reliability and robustness of the results.

Conclusion

AI has demonstrated its viability as a tool for predicting the response of GC patients to NACT Furthermore, CT-based DL model in AI was sensitive to extract tumor features and predict the response. The results of subgroup analysis also supported the above conclusions. Large-scale rigorously designed diagnostic accuracy studies and head-to-head comparative studies are anticipated.

Systematic review registration

PROSPERO, CRD42022377030.

Combining systemic inflammatory response index and albumin fibrinogen ratio to predict early serious complications and prognosis after resectable gastric cancer

BACKGROUND

Gastric cancer has a high incidence and fatality rate, and surgery is the preferred course of treatment. Nonetheless, patient survival rates are still low, and the incidence of major postoperative complications cannot be disregarded. The systemic inflammatory response, nutritional level, and coagulation status are key factors affecting the postoperative recovery and prognosis of gastric cancer patients. The systemic inflammatory response index (SIRI) and the albumin fibrinogen ratio (AFR) are two valuable comprehensive indicators of the severity and prognosis of systemic inflammation in various medical conditions.

AIM

To assess the clinical importance and prognostic significance of the SIRI scores and the AFR on early postoperative outcomes in patients undergoing radical gastric cancer surgery.

METHODS

We conducted a retrospective analysis of the clinicopathological characteristics and relevant laboratory indices of 568 gastric cancer patients from January 2018 to December 2019. We calculated and compared two indicators of inflammation and then examined the diagnostic ability of combined SIRI and AFR values for serious early postoperative complications. We scored the patients and categorized them into three groups based on their SIRI and AFR levels. COX analysis was used to compare the three groups of patients the prognostic value of various preoperative SIRI-AFR scores for 5-year overall survival (OS) and disease-free survival (DFS).

RESULTS

SIRI-AFR scores were an independent risk factor for prognosis [OS: P = 0.004; hazards ratio (HR) = 3.134; DFS: P < 0.001; HR = 3.543] and had the highest diagnostic power (area under the curve: 0.779; 95% confidence interval: 0.737-0.820) for early serious complications in patients with gastric cancer. The tumor-node-metastasis stage (P = 0.001), perioperative transfusion (P = 0.044), positive carcinoembryonic antigen (P = 0.014) findings, and major postoperative complications (P = 0.011) were factors associated with prognosis.

CONCLUSION

Preoperative SIRI and AFR values were significantly associated with early postoperative survival and the occurrence of severe complications in gastric cancer patients.

Effects of Clavien-Dindo Classification on Long-Term Survival of Patients With Advanced Gastric Cancer After Radical Resection: A Propensity Score-matched Study

BACKGROUND

The impact of postoperative complications (POCs) classified by the Clavien-Dindo (C-D) system on long-term survival after radical resection in patients with advanced gastric cancer (AGC) is not yet clear.

METHODS

This study analyzed 531 patients with AGC who underwent radical resection in an institution between January 2015 and December 2017. Patients were divided into 2 groups according to the occurrence of POCs and recorded according to C-D classifications. The long-term survival outcomes of the entire cohort after propensity score matching (PSM) were compared.

RESULTS

After PSM, there was no significant difference in baseline data between the complications (C) group (n = 92) and the non-complications (NC) group (n = 92). Survival analysis showed that the 5-year overall survival (OS) and relapse-free survival (RFS) were lower in the C group (48.9% vs 62.0%, P = .040; 38.5% vs 54.9%, P = .005; respectively). Subgroup analysis showed that severe complications (C-D grade > II) were associated with a decrease in 5-year OS and RFS compared with the matched NC group (40.0% vs 62.0%, P = .008; 29.4% vs 54.9%, P = .001; respectively). Multivariate analysis confirmed adjuvant chemotherapy, tumor size, and complications were independent risk factors for poor survival outcomes. Further multivariate analysis showed that older age, combined excision, and comorbidities were independent risk factors for POCs.

CONCLUSIONS

Severe complications reduced the survival outcome of patients. More attention should be paid to perioperative management of patients with high risk factors for complications.

Systemic inflammatory response index is a predictor of prognosis in gastric cancer patients: Retrospective cohort and meta-analysis

BACKGROUND

The systemic inflammatory response index (SIRI) has been demonstrated to make a significant difference in assessing the prognosis of patients with different solid neoplasms. However, research is needed to ascertain the accuracy and reliability of applying the SIRI to patients who undergo robotic radical gastric cancer surgery.

AIM

To validate the applicability of the SIRI in assessing the survival of gastric cancer patients and evaluate the clinical contribution of preoperative SIRI levels to predicting long-term tumor outcomes in patients, who received robotic radical gastric cancer surgery.

METHODS

Initially, an exhaustive retrieval was performed in the PubMed, the Cochrane Library, EMBASE, Web of Science, and Scopus databases to identify relevant studies. Subsequently, a meta-analysis was executed on 6 cohort studies identifying the value of the SIRI in assessing the survival of gastric cancer patients. Additionally, the clinical data of 161 patients undergoing robotic radical gastric cancer surgery were retrospectively analyzed to evaluate their clinicopathological characteristics and relevant laboratory indicators. The association between preoperative SIRI levels and 5-year overall survival (OS) and disease-free survival (DFS) was assessed.

RESULTS

The findings demonstrated an extensive connection between SIRI values and the outcome of patients with gastric cancer. Preoperative SIRI levels were identified as an independent hazard feature for both OS and DFS among those who received robotic surgery for gastric cancer. SIRI levels in gastric cancer patients were observed to be associated with the presence of comorbidities, T-stage, carcinoembryonic antigen levels, the development of early serious postoperative complications, and the rate of lymph node metastasis.

CONCLUSION

SIRI values are correlated with adverse in the gastric cancer population and have the potential to be utilized in predicting long-term oncological survival in patients who undergo robotic radical gastric cancer surgery.

Short and Long-term Efficacy of 3-dimensional Laparoscopic-assisted D2 Radical Gastrectomy Under the Guidance of Membrane Anatomy for Locally Advanced Gastric Cancer

BACKGROUND

Both 3-dimensional (3D) laparoscopy and membrane anatomy are topics of great interest in the treatment of gastric cancer. The purpose of this study was to evaluate the safety, feasibility, and efficacy of 3D laparoscopic-assisted D2 radical gastrectomy for locally advanced gastric cancer (LAGC) under the guidance of membrane anatomy.

PATIENTS AND METHODS

Retrospectively analyzed the clinical data of 210 patients who underwent 2-dimensional (2D)/3D laparoscopic-assisted D2 radical gastrectomy under the guidance of membrane anatomy for LAGC. Compared the differences between the two groups in surgical outcomes, postoperative recovery, postoperative complications, and 2-year overall survival and disease-free survival.

RESULTS

The baseline data of the 2 groups were comparable ( P > 0.05). The amount of intraoperative bleeding in the 2D and 3D laparoscopy groups was 100.1 ± 48.75 mL and 74.29 ± 47.33 mL, respectively, with a significant difference between the two groups ( P < 0.001). The time to first exhaust and first liquid diet intake and length of postoperative hospital stay was shorter in the 3D laparoscopy group, with significant differences between the two groups [3 (3-3) days vs 3(3-2) days, P = 0.009; 7 (8-7) days vs 6 (7-6) days, P < 0.001; and 13 (15-11) days vs 10 (11-9) days, P < 0.001]. There were no significant differences in operation time, number of lymph node dissections, incidence of postoperative complications, or 2-year overall survival and disease-free survival between the two groups ( P > 0.05).

CONCLUSIONS

Three-dimensional laparoscopic-assisted D2 radical gastrectomy for LAGC under the guidance of membrane anatomy is safe and feasible. It can reduce intraoperative bleeding, accelerate postoperative recovery, and does not increase operative complications, the long-term prognosis is similar to that of the 2D laparoscopy group.

Clinical implications of micro lymph node metastasis for patients with gastric cancer

BACKGROUND

Lymph node size is considered as a criterion for possible lymph node metastasis in imageology. Micro lymph nodes are easily overlooked by surgeons and pathologists. This study investigated the influencing factors and prognosis of micro lymph node metastasis in gastric cancer.

METHODS

191 eligible gastric cancer patients who underwent D2 lymphadenectomy from June 2016 to June 2017 in the Third Surgery Department at the Fourth Hospital of Hebei Medical University were retrospectively analyzed. Specimens were resected en bloc and the postoperative retrieval of micro lymph nodes was carried out by the operating surgeon for each lymph node station. Micro lymph nodes were submitted for pathological examination separately. According to the results of pathological results, patients were divided into the "micro-LNM (micro lymph node metastasis)" group (N = 85) and the "non micro-LNM" group (N = 106).

RESULTS

The total number of lymph nodes retrieved was 10,954, of which 2998 (27.37%) were micro lymph nodes. A total of 85 (44.50%) gastric cancer patients had been proven to have micro lymph node metastasis. The mean number of micro lymph nodes retrieved was 15.7. The rate of micro lymph node metastasis was 8.1% (242/2998). Undifferentiated carcinoma (90.6% vs. 56.6%, P = 0.034) and more advanced Pathological N category (P < 0.001) were significantly related to micro lymph node metastasis. The patients with micro lymph node metastasis had a poor prognosis (HR for OS of 2.199, 95% CI = 1.335-3.622, P = 0.002). For the stage III patients, micro lymph node metastasis was associated with shorter 5-year OS (15.6% vs. 43.6%, P = 0.0004).

CONCLUSIONS

Micro lymph node metastasis is an independent risk factor for poor prognosis in gastric cancer patients. Micro lymph node metastasis appears to be a supplement to N category in order to obtain more accurate pathological staging.

Aspartate β-Hydroxylase Serves as a Prognostic Biomarker for Neoadjuvant Chemotherapy in Gastric Cancer

Neoadjuvant chemotherapy (NACT) has been established as being an effective treatment for advanced gastric cancer (GC), while the predictive biomarker of NACT efficacy remains under investigation. Aspartate β-hydroxylase (ASPH) represents an attractive target which is a highly conserved transmembrane enzyme overexpressed in human GC, and participates in the malignant transformation by promoting tumor cell motility. Here, we evaluated the expression of ASPH by immunohistochemistry in 350 GC tissues (including samples for NACT) and found that ASPH expression was higher in patients undergoing NACT compared with patients without NACT pre-operation. The OS and PFS time of ASPH-intensely positive patients was significantly shorter than that of the negative patients in the NACT group, while the difference was not significant in patients without NACT. We showed that ASPH knockout enhanced the inhibitory effects of chemotherapeutic drugs on the cell proliferation, migration, and invasion in vitro and suppressed tumor progression in vivo. Co-immunoprecipitation revealed that ASPH might interact with LAPTM4B to perform chemotherapeutic drug resistance. Our results suggested that ASPH might serve as a candidate biomarker to predict prognosis and a novel therapeutic target for gastric cancer patients treated with neoadjuvant chemotherapy.

Does postoperative chemotherapy improve overall survival of patients with ypT1-2N0 cancer?

BACKGROUND

Perioperative chemotherapy combined with curative gastrectomy has been increasingly represented the standard therapeutic strategy for resectable gastric cancer (GC). However, it is still unclear whether postoperative chemotherapy has a survival benefit for ypT1-2N0 gastric cancer patients who have undergone preoperative chemotherapy followed curative gastrectomy.

METHODS

The data of patients who undergone neoadjuvant chemotherapy followed by gastrectomy and had pathological classification of ypT1-2N0 between March 2016 and December 2020 at Peking Union Medical College Hospital were retrospectively reviewed. Chi-square test was adopted to compare the difference between the patients with postoperative chemotherapy (pCHT) and without postoperative chemotherapy (no pCHT). Survival curves for overall survival (OS) were estimated using the Kaplan-Meier method, and the log-rank test was used to compare survival difference. Univariate and multivariate analyses for prognostic factors were based on the Cox regression.

RESULTS

A total of 134 patients met the inclusion criteria and 56 (41.8%) of them have undergone postoperative chemotherapy. There were no statistically significant differences in demographic and clinicopathologic characteristics between pCHT group and no pCHT group (all p > 0.05). Postoperative chemotherapy was not associated with a significant improvement in overall survival (OS) (Hazard ratio [HR] 0.815, 95% confidence interval [CI] 0.403-1.650; p = 0.474). Subgroup analyses demonstrated survival was equivalent between pCHT and no CHT group in ypT1N0 patients (HR 0.832, CI 0.222-3.121; p = 0.786) and ypT2N0 patients (HR 1.284, CI 0.564-2.924; p = 0.551). Multivariable analysis identified that clinical T stage independently influenced prognosis (cT3 vs. cT2: HR 2.875, 95% CI 0.998-8.281, p = 0.050; cT4 vs. cT2: HR 7.382, 95% CI 2.569-21.211, p < 0.001). In clinical T3-4 patients, there was an overall survival benefit for postoperative chemotherapy (HR 0.270, 95% CI 0.114-0.634; p = 0.006). No survival benefit of postoperative chemotherapy was identified in clinical T2 patients (HR 0.689, 95% CI 0.200-2.372; p = 0.579). Furthermore, postoperative chemotherapy was proved to be an independently positive prognostic factor for clinical T3-4 patients (HR 0.132, 95% CI 0.051-0.345; p < 0.001).

CONCLUSION

Postoperative chemotherapy might offer survival benefit to patients with ypT1-2N0 gastric cancer whose clinical T stage was T3-4 before preoperative chemotherapy.

The validity of neoadjuvant chemotherapy with paclitaxel plus S-1 is not inferior to that of SOX regimen for locally advanced gastric cancer: an observational study

BACKGROUND

Paclitaxel plus S-1(PTXS) has shown definite efficacy for advanced gastric cancer. However, the efficacy and safety of this regimen in neoadjuvant setting for locally advanced gastric cancer (LAGC) are unclear. This study aimed to compare the efficacy of neoadjuvant chemotherapy (NAC) PTXS and oxaliplatin plus S-1 (SOX) regime for patients with LAGC.

METHODS

A total of 103 patients with LAGC (cT3/4NanyM0/x) who were treated with three cycles of neoadjuvant SOX regimen (n = 77) or PTXS regimen (n = 26) between 2011 and 2017 were enrolled in this study. NAC-related clinical response, pathological response, postoperative complication, and overall survival were analyzed between the groups.

RESULTS

The baseline data did not differ significantly between both groups. After NAC, the disease control rate of the SOX group (94.8%) was comparable with that of the PTXS group (92.3%) (p = 0.641). Twenty-three cases (29.9%) in the SOX group and 10 cases (38.5%) in the PTX group got the descending stage with no statistical difference (p = 0.417). No significant differences were observed in the overall pathological response rate and the overall postoperative complication rate between the two groups (p > 0.05). There were also no differences between groups in terms of 5-year overall and disease-free survival (p > 0.05).

CONCLUSIONS

The validity of NAC PTXS was not inferior to that of SOX regimen for locally advanced gastric cancer in terms of treatment response and overall survival. PTXS regimen could be expected to be ideal neoadjuvant chemotherapy for patients with LAGC and should be adopted for the test arm of a large randomized controlled trial.

Risk Factors and Prognostic Impact of Postoperative Complications in Patients with Advanced Gastric Cancer Receiving Neoadjuvant Chemotherapy

Background: Neoadjuvant chemotherapy is important to improve the prognosis of patients with advanced gastric cancer. However, it may result in postoperative complications (POCs). The aim of this study is to evaluate risk factors and prognostic impact of POCs in patients receiving neoadjuvant chemotherapy. Methods: We retrospectively collected clinical information of patients who underwent curative gastrectomy after receiving neoadjuvant chemotherapy between 2011 and 2018. Overall survival (OS) was analyzed using the Kaplan–Meier method. Logistic regression and Fisher’s exact test were used to evaluate risk factors for complications. Results: A total of 176 patients were included in our study. The 3-year OS rates for the complication group (n = 30) and non-complication group (n = 146) were 36.7% and 52.7%, respectively (p = 0.0294). Age, BMI, multivisceral resection and operation time were independent risk factors for POCs in patients. Patients with multivisceral resection were more likely to suffer from grade III-IV complications (p = 0.026). Inflammation complications might occur in patients with high BMI (p = 0.017). Low preoperative albumin seemed to be a risk factor for leakage complications (p = 0.033). Conclusions: Our study revealed that patients with POCs had a poor prognosis and we identified the risk factors for complications so that POCs can be avoided in time.

The Impact of Perioperative Events on Cancer Recurrence and Metastasis in Patients after Radical Gastrectomy: A Review

Radical gastrectomy is a mainstay therapy for patients with locally resectable gastric cancer (GC). GC patients who are candidates for radical gastrectomy will experience at least part of the following perioperative events: surgery, anesthesia, pain, intraoperative blood loss, allogeneic blood transfusion, postoperative complications, and their related anxiety, depression and stress response. Considerable clinical studies have shown that these perioperative events can promote recurrence and decrease the long-term survival of GC patients. The mechanisms include activation of neural signaling and the inflammatory response, suppression of antimetastatic immunity, increased release of cancer cells into circulation, and delayed adjuvant therapy, which are involved in every step of the invasion-metastasis cascade. Having appreciated these perioperative events and their influence on the risk of GC recurrence, we can now use this knowledge to find strategies that might substantially prevent the deleterious recurrence-promoting effects of perioperative events, potentially increasing cancer-free survival in GC patients.

CT-Based Radiomics Showing Generalization to Predict Tumor Regression Grade for Advanced Gastric Cancer Treated With Neoadjuvant Chemotherapy

Objective

The aim of this study was to develop and validate a radiomics model to predict treatment response in patients with advanced gastric cancer (AGC) sensitive to neoadjuvant therapies and verify its generalization among different regimens, including neoadjuvant chemotherapy (NAC) and molecular targeted therapy.

Materials and Methods

A total of 373 patients with AGC receiving neoadjuvant therapies were enrolled from five cohorts. Four cohorts of patients received different regimens of NAC, including three retrospective cohorts (training cohort and internal and external validation cohorts) and a prospective Dragon III cohort (NCT03636893). Another prospective SOXA (apatinib in combination with S-1 and oxaliplatin) cohort received neoadjuvant molecular targeted therapy (ChiCTR-OPC-16010061). All patients underwent computed tomography before treatment, and thereafter, tumor regression grade (TRG) was assessed. The primary tumor was delineated, and 2,452 radiomics features were extracted for each patient. Mutual information and random forest were used for dimensionality reduction and modeling. The performance of the radiomics model to predict TRG under different neoadjuvant therapies was evaluated.

Results

There were 28 radiomics features selected. The radiomics model showed generalization to predict TRG for AGC patients across different NAC regimens, with areas under the curve (AUCs) (95% interval confidence) of 0.82 (0.76~0.90), 0.77 (0.63~0.91), 0.78 (0.66~0.89), and 0.72 (0.66~0.89) in the four cohorts, with no statistical difference observed (all p > 0.05). However, the radiomics model showed poor predictive value on the SOXA cohort [AUC, 0.50 (0.27~0.73)], which was significantly worse than that in the training cohort (p = 0.010).

Conclusion

Radiomics is generalizable to predict TRG for AGC patients receiving NAC treatments, which is beneficial to transform appropriate treatment, especially for those insensitive to NAC.

Effect of neoadjuvant treatment combined with radical gastrectomy on postoperative complications and prognosis of gastric cancer patients

OBJECTIVE

To investigate the occurrence of postoperative complications in and factors influencing the prognosis of patients undergoing radical gastrectomy after neoadjuvant chemotherapy.

METHODS

A total of 238 patients with gastric cancer were enrolled in this study. There were 194 patients who underwent neoadjuvant chemotherapy before surgery and 44 patients who underwent concurrent radiochemotherapy before surgery. The clinical data of patients and the incidence of postoperative complications were collected. Postoperative complications were graded based on the Clavien-Dindo classification. The impact of postoperative complications on the prognosis of patients was analysed.

RESULTS

(1) The overall incidence of postoperative complications was 17.2% (41/238) among all patients. A total of 49 patients experienced postoperative complications, including 12 cases of grade I, 15 cases of grade II, seven cases of grade IIIa, three cases of grade IIIb, seven cases of grade IV, and four cases of grade V complications. A total of 21 patients experienced severe complications. Multivariate analysis indicated that age, body mass index (BMI), and scope of gastrectomy were independent risk factors for postoperative complications (p < .05). (2) The five-year survival rate for the entire group of patients was 58.4%. The five-year survival rate for the complication group and non-complication group were 31.7% and 51.7%, respectively, with a significant difference between the two groups (χ²=15.41p = .000). Based on the severity of complications, the subgroup analysis indicated that the five-year survival rate for patients with severe postoperative complications was 21.1% and that for patients with non-severe complications was 40.9%; the difference was significant (χ²=21.70, p = .000). (3) Multivariate analysis indicated that age, pathological tumour, node, and metastasis (ypTNM) stages II-III, operation time >3.5 h, total gastrectomy, and postoperative complications were independent risk factors affecting the prognosis of patients undergoing radical gastrectomy after neoadjuvant chemotherapy. Postoperative adjuvant therapy was an independent protective factor for patient prognosis (p < .05).

CONCLUSION

The incidence of complications in patients undergoing radical gastrectomy after neoadjuvant chemotherapy is closely correlated with patient age and the scope of surgical resection, and the occurrence of severe complications has a significant adverse effect on patient prognosis.

The Chinese Society of Clinical Oncology (CSCO): Clinical guidelines for the diagnosis and treatment of gastric cancer, 2021

There exist differences in the epidemiological characteristics, clinicopathological features, tumor biological characteristics, treatment patterns, and drug selections between gastric cancer patients from the Eastern and Western countries. The Chinese Society of Clinical Oncology (CSCO) has organized a panel of senior experts specializing in all sub-specialties of gastric cancer to compile a clinical guideline for the diagnosis and treatment of gastric cancer since 2016 and renews it annually. Taking into account regional differences, giving full consideration to the accessibility of diagnosis and treatment resources, these experts have conducted expert consensus judgment on relevant evidence and made various grades of recommendations for the clinical diagnosis and treatment of gastric cancer to reflect the value of cancer treatment and meeting health economic indexes in China. The 2021 CSCO Clinical Practice Guidelines for Gastric Cancer covers the diagnosis, treatment, follow-up, and screening of gastric cancer. Based on the 2020 version of the CSCO Chinese Gastric Cancer guidelines, this updated guideline integrates the results of major clinical studies from China and overseas for the past year, focused on the inclusion of research data from the Chinese population for more personalized and clinically relevant recommendations. For the comprehensive treatment of non-metastatic gastric cancer, attentions were paid to neoadjuvant treatment. The value of perioperative chemotherapy is gradually becoming clearer and its recommendation level has been updated. For the comprehensive treatment of metastatic gastric cancer, recommendations for immunotherapy were included, and immune checkpoint inhibitors from third-line to the first-line of treatment for different patient groups with detailed notes are provided.

Body composition parameters predict pathological response and outcomes in locally advanced gastric cancer after neoadjuvant treatment: A multicenter, international study

BACKGROUND

Body composition profiles influence the prognosis of several types of cancer; however, the role of body composition in patients with locally advanced gastric cancer (LAGC) after neoadjuvant treatment (NT) has not been well characterized.

PATIENTS AND METHODS

A total of 213 patients with LAGC who underwent gastrectomy after NT at a high-volume institution from southern China were comprehensively evaluated for primary analysis. Additionally, 170 and 77 patients from Western China and Italy, respectively, were reviewed for external validation. The skeletal muscle index (SMI), skeletal muscle radiodensity (SMD), and the subcutaneous as well as the visceral adiposity index were assessed from clinically acquired CT scans at diagnosis and preoperatively.

RESULTS

Overall, none of the body composition parameters significantly changed after NT. The pre-NT skeletal muscle radiodensity (SMD) and change in SMI (ΔSMI) were both significantly lower in the patients with poor response (tumor regression <50%; mean SMD: 43.5 vs 46.5, P = 0.003; mean ΔSMI: -1.0 vs 2.2, P < 0.001), and the cutoff values were calculated according to the Youden index as 43.7 and 1.2, respectively. Based on these 2 parameters, a novel model, the Skeletal Muscle Score (SMS), was proposed to predict the pathological response (AUC = 0.764 alone and = 0.822 in combination with the radiological response). Moreover, patients with an SMI loss >1.2 had a significantly prolonged drainage tube removal time (mean: 10.0 vs 8.2, P = 0.003) and postoperative hospital stay (mean: 11.1 vs 9.8, P = 0.048), as well as a significantly higher rate of postoperative complications (30.9% vs 16.7%, P = 0.015). In the multivariate analysis, SMI loss >1.2 independently predicted poor overall survival (HR: 1.677, 95% CI 1.040-2.704, P = 0.034) and recurrence-free survival (HR: 1.924, 95% CI 1.165-3.175, P = 0.011). ΔSMI was also significantly associated with pathological response, surgical outcomes, and survival in the 2 external cohorts (P all < 0.05).

CONCLUSIONS

For LAGC, the pre-NT SMD and ΔSMI could accurately predict the pathological response after NT. An SMI loss >1.2 is closely associated with poorer outcomes and may indicate the need more supportive treatment.

Relationship Between Postoperative Complications and the Prognosis of Gastric Carcinoma Patients Who Underwent Surgical Resection: A Systematic Review and Meta-Analysis

Background:

Whether the presence of postoperative complications was associated with poor prognosis of gastric carcinoma (GC) patients remain controversial. This meta-analysis was designed and reported to compare the survival difference between patients with complications and non-complications.

Methods:

Cochrane Library, PubMed and Embase databases were comprehensively searched for published literatures to review current evidence on this topic. The survival data were extracted, and a random-effect or fixed-effect model was used to analyze the correlation between postoperative complications and oncologic outcome of GC patients.

Results:

Of all studies identified, 32 were eligible for this pooled analysis, with a total of 32,067 GC patients. The incidence of postoperative complications was approximately 12.5% to 51.0%. Among them, infectious complications varied from 3.0% to 28.6%, anastomotic leakage varied from 1.1% to 8.7% and postoperative pneumonia varied from 1.6% to 12.8%. The presence of postoperative complications resulted in a significant poorer overall survival (OS) of gastric carcinoma patients (hazard ratio [HR]:1.49, 95% confidence interval [CI]: 1.33-1.67, P < 0.001). Additionally, the pooled results showed a significant correlation between infectious complications and decreased OS (HR: 1.61, 95%CI: 1.38-1.88, P < 0.001). Concerning specific postoperative complications, we found that both anastomotic leakage (HR: 2.36, 95%CI: 1.62-3.42, P < 0.001) and postoperative pneumonia (HR: 1.74, 95%CI: 1.22-2.49, P = 0.002) impaired the OS of gastric carcinoma patients.

Conclusion:

Postoperative complications were significantly correlated to recurrence and poor survival in gastric carcinoma patients. To gain a better surgical outcome and long-term oncological outcome, postoperative complications should be minimized as much as possible.

Lymph Node Involvement in Advanced Gastric Cancer in the Era of Multimodal Treatment-Oncological and Surgical Perspective

Simple Summary

Gastric cancer (GC) continues to be one of the major oncological challenges on a global scale. The role of neoadjuvant chemotherapy (NAC) in GC is to downstage primary tumour, eliminate potential micrometastases, and increase the chance for radical resection. Although systemic treatment prolongs the survival in advanced GC, persistent lymph node (LN) metastases indicate poor prognosis. Therefore, further identification of prognostic factors after NAC is urgent and could positively influence clinical outcomes. This article aimed to review the actual trends and future perspectives in multimodal therapy of advanced GC, with a particular interest in the post-neoadjuvant pathological nodal stage. Since downstaged and primarily node-negative patients show a similar prognosis, the main target for NAC in advanced GC should be nodal clearance. Adequate staging and personalised perioperative therapy seem to be of great importance in the multimodal treatment of GC.

Abstract

Gastric cancer (GC) continues to be one of the major oncological challenges on a global scale. The role of neoadjuvant chemotherapy (NAC) in GC is to downstage primary tumour, eliminate potential micrometastases, and increase the chance for radical resection. Although systemic treatment prolongs the survival in advanced GC, persistent lymph node (LN) metastases indicate poor prognosis. Further identification of prognostic factors after NAC is urgent and could positively influence clinical outcomes. This article aimed to review the actual trends and future perspectives in multimodal therapy of advanced GC, with a particular interest in the post-neoadjuvant pathological nodal stage. A favourable prognostic impact for ypN0 patients is observed, either due to truly negative LN before the start of therapy or because preoperative therapy achieved a pathologically complete nodal response. Ongoing trials investigating the extent of lymphadenectomy after neoadjuvant therapy will standardise the LN dissection from the multimodal therapy perspective. Since downstaged and primarily node-negative patients show a similar prognosis, the main target for NAC in advanced GC should be nodal clearance. Adequate staging and personalised perioperative therapy seem to be of great importance in the multimodal treatment of GC.

Laparoscopic gastrectomy for stage II and III advanced gastric cancer: long‑term follow‑up data from a Western multicenter retrospective study

Introduction

There has been an increasing interest for the laparoscopic treatment of early gastric cancer, especially among Eastern surgeons. However, the oncological effectiveness of Laparoscopic Gastrectomy (LG) for Advanced Gastric Cancer (AGC) remains a subject of debate, especially in Western countries where limited reports have been published. The aim of this paper is to retrospectively analyze short- and long-term results of LG for AGC in a real-life Western practice.

Materials and methods

All consecutive cases of LG with D2 lymphadenectomy for AGC performed from January 2005 to December 2019 at seven different surgical departments were analyzed retrospectively. The primary outcome was diseases-free survival (DFS). Secondary outcomes were overall survival (OS), number of retrieved lymph nodes, postoperative morbidity and conversion rate.

Results

A total of 366 patients with stage II and III AGC underwent either total or subtotal LG. The mean number of harvested lymph nodes was 25 ± 14. The mean hospital stay was 13 ± 10 days and overall postoperative morbidity rate 27.32%, with severe complications (grade ≥ III) accounting for 9.29%. The median follow-up was 36 ± 16 months during which 90 deaths occurred, all due to disease progression. The DFS and OS probability was equal to 0.85 (95% CI 0.81–0.89) and 0.94 (95% CI 0.92–0.97) at 1 year, 0.62 (95% CI 0.55–0.69) and 0.63 (95% CI 0.56–0.71) at 5 years, respectively.

Conclusion

Our study has led us to conclude that LG for AGC is feasible and safe in the general practice of Western institutions when performed by trained surgeons.

Preoperative chemotherapy could modify recurrence patterns through postoperative complications in patients with gastric cancer

PURPOSE

Postoperative infectious complications have a negative impact on survival outcomes in patients with gastric cancer. It is recently reported that preoperative chemotherapy may eliminate this negative impact. This study aimed to confirm whether preoperative chemotherapy can eliminate the negative impact of postoperative infectious complications (IC) on survival outcomes and elucidate the association between postoperative infectious complications and recurrence patterns.

METHODS

We retrospectively reviewed data of 86 patients who received preoperative chemotherapy with docetaxel, cisplatin, and S-1 followed by R0 gastrectomy at the Kitasato University between 2006 and 2016. Patients who developed grade II or higher infectious complications during hospitalization were grouped into the IC group, while others were grouped into the non-IC (NIC) group. Survival outcomes and recurrence patterns were analyzed between the two groups.

RESULTS

Infectious complications with Clavien-Dindo classification of grade II or higher were found in 12 patients (14.0%, IC group). The median observational period was 61 months. Overall survival and progression-free survival were similar in the IC and NIC groups. Recurrence occurred in 39 patients. The proportions of peritoneal and lymph node recurrences were not significantly different between the two groups. However, the proportion of distant metastasis in the IC group was significantly higher than that in NIC group (3/4 [75%] vs. 9/35 [17%], p = 0.04).

CONCLUSIONS

Pathological stage after neoadjuvant therapy plays a stronger role in recurrence than postoperative complications. Lymph node and peritoneal metastasis may be suppressed by preoperative chemotherapy.

Feasibility and Safety of Perioperative Chemotherapy With Fluorouracil Plus Leucovorin, Oxaliplatin, and Docetaxel for Locally Advanced Gastric Cancer Patients in China

Background

Neoadjuvant fluorouracil plus leucovorin, oxaliplatin, and docetaxel (FLOT) has shown significant benefits for gastric cancer patients. However, it has not been well accepted in Asian countries. We conducted a prospective study on the safety and feasibility of the FLOT regimen in Chinese patients.

Methods

Patients with adenocarcinoma of the stomach or esophagogastric junction received four cycles of neoadjuvant chemotherapy (NAC) and four cycles of adjuvant chemotherapy (AC) with the FLOT regimen. The completion status of chemotherapy, adverse events, postoperative morbidities, and pathological tumor regression were analyzed. The 2-year overall survival (OS) and relapse-free survival are presented.

Results

Altogether, 10 patients were enrolled, and all patients completed four cycles of neoadjuvant chemotherapy. There were no severe hematological adverse events (grade 3 or above), except for a case of grade 3 anemia. All 10 patients underwent radical gastrectomy. Nine patients had R0 resection, and three patients had complete or subtotal pathological tumor regression. Nine patients completed four cycles of adjuvant chemotherapy, but only one patient completed the full dose of adjuvant chemotherapy. The dose of adjuvant chemotherapy was reduced by 25% or less in the other patients. The median follow-up time was 23.13 months, eight patients achieved the overall survival endpoint, and seven patients had relapse-free survival for this period. Two patients died of disease progression.

Conclusions

Our study demonstrates that the neoadjuvant FLOT regimen is safe and effective for Chinese patients. Dose adjustment is necessary for adjuvant chemotherapy. The pathological regression and survival rates need reevaluation in a larger cohort. The trial is registered with ClinicalTrials.gov (number NCT03646591).

Perioperative CRP: A novel inflammation-based classification in gastric cancer for recurrence and chemotherapy benefit

Background

Perioperative C‐reactive protein (CRP) levels have effects on the prognosis of cancer patients. We intended to determine the prognostic value of combining the two for gastric cancer (GC).

Methods

Data were extracted from a clinical trial. By calculating the area under the curve (AUC) and the C‐index, the predictive value of CRPs among different time points, including preoperative (pre‐CRP), postoperative days 1, 3, and 5 (post‐CRPs), and postoperative maximum CRP (post‐CRP_max), was derived. Multivariate analysis was performed to further explore the independent variates for recurrence‐free survival (RFS).

Results

Finally, 401 patients were available in the present study. For RFS, higher AUC (0.692) and concordance index (0.678) of pre‐CRP were observed when compared with those of post‐CRPs. Further, among post‐CRPs, post‐CRP_max had the highest predictive values (AUC: 0.591; concordance index: 0.585) among the other post‐CRPs. The threshold values in predicting RFS for pre‐CRP and post‐CRP_max were 3.1 mg/L and 77.1 mg/L. Multivariate analysis showed both pre‐CRP≥3.1 mg/L (high‐pre‐CRP) and post‐CRP_max≥77.1 mg/L (high‐post‐CRP_max) were risk factors for RFS. Postoperative chemotherapy benefit was further analyzed for patients with stage II/III GC and indicated that patients with pre‐CRP<3.1 mg/L had better prognosis without benefit from postoperative adjuvant chemotherapy (ACT), p = 0.557. In high‐pre‐CRP patients, only patients with post‐CRP_max≥77.1 mg/L but not post‐CRP_max<77.1 mg/L benefited from postoperative ACT (RFS: 33.2% vs 49.9% for non‐chemotherapy group and chemotherapy group, respectively, p = 0.037). Analyses for overall survival obtained the similar outcomes.

Conclusions

Both high‐pre‐CRP and high‐post‐CRP_max are associated with worse prognosis in GC. ACT seems to only improve the prognosis for stage II/III GC with pre‐CRP≥3.1 mg/L and post‐CRP_max≥77.1 mg/L after radical gastrectomy. Further studies are needed to confirm these findings and explore the potential mechanism.

Neoadjuvant FLOT versus SOX phase II randomized clinical trial for patients with locally advanced gastric cancer

Neoadjuvant chemotherapy with docetaxel, oxaliplatin, fluorouracil, and leucovorin (FLOT regimen) has shown promising results in terms of pathological response and survival rate in patients with locally advanced resectable gastric cancer (LAGC). However, tegafur gimeracil oteracil potassium capsule (S-1) plus oxaliplatin (SOX regimen) is the preferred chemotherapy regimen in Eastern countries. Here, we conduct an open label, two-arm, phase II randomized interventional clinical trial (Dragon III; ClinicalTrials.gov: NCT03636893) to evaluate the safety and efficacy of both regimens. Patients with LAGC are randomly assigned to receive either 4 cycles of the neoadjuvant FLOT regimen (40 patients) or 3 cycles of the SOX regimen (34 patients) before gastrectomy. The primary endpoint is the comparison of complete (TRG1a) or subtotal (TRG1b) tumor regression grading in the primary tumor. There are no significant differences in adverse effects or postoperative morbidity and mortality between the two groups. No significant differences in the proportion of tumor regression grading between the FLOT group and the SOX group are found. Complete or subtotal TRG is 20.0% in the FLOT group versus 32.4% in the SOX group. Therefore, our study does not find statistically significant differences between neoadjuvant FLOT and SOX regimens for the primary outcomes reported here in locally advanced gastric cancer.

Postoperative pancreatic fistulas decrease the survival of pancreatic cancer patients treated with surgery after neoadjuvant chemoradiotherapy: A retrospective analysis

BACKGROUND AND OBJECTIVES

A postoperative pancreatic fistula (POPF) is a critical complication after surgery for pancreatic cancer. Whether a POPF affects the long-term prognosis of pancreatic cancer cases remains controversial. This study aimed to clarify the effect of a POPF on the long-term prognosis of pancreatic cancer patients, especially after neoadjuvant chemoradiotherapy (NACRT).

METHODS

Patients who underwent curative pancreatectomy for pancreatic cancer between January 2012 and June 2019 at Kyoto University Hospital were retrospectively investigated. A fistula ≥ Grade B was considered a POPF.

RESULTS

During the study period, 148 patients underwent upfront surgery (Upfront group), and 52 patients underwent surgery after NACRT (NACRT group). A POPF developed in 16% of patients in the Upfront group and 13% in the NACRT group (p = 0.824). In the Upfront group, development of a POPF did not have a significant effect on recurrence-free survival (p = 0.766) or overall survival (p = 0.863). However, in the NACRT group, development of a POPF significantly decreased recurrence-free survival (HR 5.856, p = 0.002) and overall survival (HR 7.097, p = 0.020) on multivariate analysis.

CONCLUSIONS

The development of a POPF decreases the survival of pancreatic cancer patients treated by surgery after NACRT.

Intraoperative blood loss as an independent prognostic factor for curative resection after neoadjuvant chemotherapy for gastric cancer: a single-center retrospective cohort study

PURPOSE

Surgery-induced factors such as postoperative infectious complications (PICs) and intraoperative blood loss (IBL) have a negative impact on the survival of patients undergoing surgery for gastric cancer. A recent study showed that neoadjuvant chemotherapy (NAC) could reduce the negative impact of PICs; hence, we conducted the present study to investigate if NAC can also reduce the negative prognostic impact of IBL.

METHODS

We reviewed 115 gastric cancer patients treated with NAC and radical gastrectomy. The cut-off for IBL predicting the long-term survival was assessed by a receiver operating characteristic curve. The Cox proportional hazard model was used to evaluate the association between patient characteristics including IBL, overall survival, and disease-free survival.

RESULTS

The cut-off for IBL was set at 990 ml. Twenty-six patients had excessive IBL exceeding 990 ml (22.6%) and PICs developed in 33 patients (28.7%). The body mass index, IBL, ypT, and ypN were significant independent prognostic predictors, but PICs were not.

CONCLUSION

NAC did not decrease the risk induced by excessive IBL. The prophylactic effect of NAC on surgery-induced risk was inconsistent.

Tumor Regression Grade Predicts Survival in Locally Advanced Gastric Adenocarcinoma Patients with Lymph Node Metastasis

Background

Tumor regression grade (TRG) is widely used in gastrointestinal carcinoma to evaluate pathological responses to neoadjuvant chemotherapy (NCT), but whether it is an independent prognostic factor is still controversial. The aim of this study is to investigate the value of TRG in locally advanced gastric adenocarcinoma patients who underwent NCT and curative resection.

Methods

Pathological regression was reevaluated according to the Mandard TRG. Survival curves were obtained by the Kaplan–Meier method, and differences in overall survival (OS) and disease-free survival (DFS) were compared using the log-rank test. Univariate and multivariate analyses for survival were based on the Cox proportional hazards method.

Results

In total, 290 patients were identified in our electronic database. In univariable analysis, TRG was associated with OS (HR = 3.822, P ≤ 0.001) and DFS (HR = 3.374, P ≤ 0.001). However, in multivariable analysis, TRG was not an independent factor for OS (P = 0.231) or DFS (P = 0.191). In the stratified analysis, TRG retrieved prognostic significance in patients with the metastasis of lymph node (HR = 2.034, P = 0.035 for OS; HR = 2.220, P = 0.016 for DFS), while not in patients with negative lymph node (P = 0.296 for OS; P = 0.172 for DFS).

Conclusions

TRG was not an independent predictor for survival, but the system regained its predicting significance in patients with lymph node metastasis.

Neoadjuvant chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel (FLOT) for gastric cancer patients in China (Preprint).. [DOI: 10.2196/preprints.22615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

BACKGROUND

Neoadjuvant chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel (FLOT) has shown significant benefits for gastric cancer patients. However, it has not been well accepted in Asian countries.

OBJECTIVE

So we conducted a prospective study on the safety and feasibility of this regimen in Chinese patients.

METHODS

Patients with adenocarcinoma of the stomach or esophagogastric received 4 cycles of neoadjuvant chemotherapy (NAC) and 4 cycles of adjuvant chemotherapy (AC) with the FLOT regimen. The completion status of chemotherapy, adverse events, postoperative morbidities and pathological tumor regression were analyzed. The two-year overall survival (OS) and relapse-free survival are presented. The trial is registered with ClinicalTrials.gov (number NCT03646591).

RESULTS

Altogether, 10 patients were enrolled, and all patients completed 4 cycles of neoadjuvant chemotherapy. There were no severe hematological adverse events (grade 3 or above), except for a case of grade 3 anemia. Four patients had grade 3 or 4 vomiting, and all other non-hematological adverse events were grade 2 or below. All 10 patients underwent radical gastrectomy. There was no anastomotic leakage, reoperation or death due to surgical complications. Nine patients had R0 resection, and 3 patients had complete or subtotal pathological tumor regression. Nine patients completed 4 cycles of adjuvant chemotherapy, but only one patient completed the full dose of adjuvant chemotherapy. The dose of adjuvant chemotherapy was reduced by 25% or less in the other patients. The median follow-up time was 23.13 months, 8 patients achieved the overall survival endpoint, and 7 patients had relapse-free survival for this period. Two patients died of disease progression.

CONCLUSIONS

Our study demonstrates that the neoadjuvant FLOT regimen is safe and effective for Chinese patients. Dose adjustment is necessary for adjuvant chemotherapy. The pathological regression and survival rates need reevaluation in a larger cohort.

Dragon III- Phase II Randomized Controlled Trial: Neoadjuvant FLOT versus SOX for Patients with Locally Advanced Gastric Cancer.. [DOI: 10.1101/2020.06.21.20136887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background

Neoadjuvant chemotherapy with docetaxel, oxaliplatin, fluorouracil, and leucovorin (the FLOT regimen) has shown promising results in terms of pathological response and survival rate. However, tegafur gimeracil oteracil potassium capsule (S-1) plus oxaliplatin (the SOX regimen) is a more favorable chemotherapy regimen in Eastern countries. We conducted this study to evaluate the safety and efficacy of both regimens and to explore a suitable regimen for gastric cancer patients.

Methods

Patients with locally advanced gastric cancer (LAGC) were 1:1 randomly assigned to receive either 4 cycles of the FLOT regimen or 3 cycles of the SOX regimen before curative gastrectomy. The primary endpoint was the comparison of complete or subtotal tumor regression grading (TRG1a+ TRG1b) in the primary tumor.

Results

Altogether, 74 patients were enrolled between August 2018 and March 2020. There was no significant difference in pretreatment clinicopathological parameters between the FLOT group and the SOX group (p>0.05). There was no significant difference in adverse effects or postoperative morbidity and mortality between the two groups (p>0.05). Similarly, there was no significant difference in the proportion of tumor regression grading between the FLOT group and the SOX group (p>0.05). In the ITT population, complete or subtotal TRG was 20.0% in the FLOT group versus 32.4% in the SOX group (p>0.05).

Conclusion

Our study demonstrates that the FLOT and SOX regimens are similarly effective for locally advanced gastric cancer patients in terms of clinical downstaging and pathological response. A large-scale phase III randomized controlled trial is necessary to validate this result.

Effects of Neoadjuvant Chemotherapy Toxicity and Postoperative Complications on Short-term and Long-term Outcomes After Curative Resection of Gastric Cancer

BACKGROUND

Whether neoadjuvant chemotherapy (NAC) increased the risk of postoperative morbidities for patients with locally advanced gastric cancer (GC) is unknown. Whether neoadjuvant chemotherapy toxicity (NCT) and postoperative complications (POCs) correlate with short-term and long-term outcomes also remains unclear. We aimed to evaluate the role of NAC on the development of POCs, as well as the impact of NCT and POCs on postoperative and oncologic outcomes in curatively resected GC treated with NAC.

METHODS

This study retrospectively reviewed 230 patients who underwent curative gastrectomy for locally advanced GC (clinically T3/4 or N+) after NAC between 2006 and 2016. Five hundred patients undergoing upfront and curative surgery were selected as a control group. After matching, the incidence of POCs was compared between two groups. In the NAC group, clinicopathological characteristics of patients who experienced POCs were compared to those who did not. Logistic and Cox multivariate regression analyses were used to examine factors associated with POCs, disease-free survival (DFS), and overall survival (OS).

RESULTS

Following matching, 230 and 230 patients treated with surgery plus NAC and upfront surgery remained, respectively. The incidence of POCs was 28.7% and 24.3%, respectively (p = 0.290). In the NAC group, NCT (OR [odds ratio] 22.968, 95% CI [confidence interval] 2.948-> 99, p = 0.003) and operation time (OR 1.006, 95% CI 1.001-1.011, p = 0.021) were independent predictive factors of POCs. NCT did not affect oncologic outcomes. The Cox regression model demonstrated that POCs were independently associated with worse DFS (HR [hazard ratio] 2.128, 95% CI 1.240-3.653, p = 0.006) but not OS for patients treated with NAC.

CONCLUSIONS

The administration of NAC is not associated with an elevated risk of POCs. For patients treated with NAC, NCT is an independent predictor of POCs, but does not affect oncologic outcomes. POCs is independently associated with worse DFS but not OS. NAC should be considered a safe approach in patients who have locally advanced GC. Strategies to minimize chemotherapy toxicity and postoperative morbidities associated with NAC are warranted.

Dragon III- Phase 1: Feasibility and safety of neoadjuvant chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel (FLOT) for locally-advanced gastric cancer patients in China.. [DOI: 10.1101/2020.05.22.20110668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background

Neoadjuvant fluorouracil plus leucovorin, oxaliplatin, and docetaxel (FLOT) has shown significant benefits for gastric cancer patients. However, it has not been well accepted in Asian countries. We conducted a prospective study on the safety and feasibility of FLOT regimen in Chinese patients.

Methods

Patients with adenocarcinoma of the stomach or esophagogastric junction received 4 cycles of neoadjuvant chemotherapy (NAC) and 4 cycles of adjuvant chemotherapy (AC) with the FLOT regimen. The completion status of chemotherapy, adverse events, postoperative morbidities and pathological tumor regression were analyzed. The two-year overall survival (OS) and relapse-free survival are presented.

Results

Altogether, 10 patients were enrolled, and all patients completed 4 cycles of neoadjuvant chemotherapy. There were no severe hematological adverse events (grade 3 or above), except for a case of grade 3 anemia. All 10 patients underwent radical gastrectomy. Nine patients had R0 resection, and 3 patients had complete or subtotal pathological tumor regression. Nine patients completed 4 cycles of adjuvant chemotherapy, but only one patient completed the full dose of adjuvant chemotherapy. The dose of adjuvant chemotherapy was reduced by 25% or less in the other patients. The median follow-up time was 23.13 months, 8 patients achieved the overall survival endpoint, and 7 patients had relapse-free survival for this period. Two patients died of disease progression.

Conclusions

Our study demonstrates that the neoadjuvant FLOT regimen is safe and effective for Chinese patients. Dose adjustment is necessary for adjuvant chemotherapy. The pathological regression and survival rates need reevaluation in a larger cohort.

The trial is registered with ClinicalTrials.gov (number NCT03646591).

Delaying adjuvant chemotherapy in advanced gastric cancer patients: Risk factors and its impact on survival outcome

Adjuvant chemotherapy following the curative resection could improve the survival outcome of advanced gastric cancer (GC) patients. However, it is unclear whether delayed initiation of adjuvant chemotherapy had a negative impact on survival outcome in GC patients. The purpose of this study was to review current published literature about the impact of delaying adjuvant chemotherapy on survival outcome and summarize risk factors for delaying adjuvant chemotherapy. Delayed initiation of adjuvant chemotherapy was quite frequent in GC patients who underwent gastrectomy due to postoperative complications, poor nutritional status, comorbid diseases and socioeconomic status. Therefore, it is important for these patients to have a sufficient and smooth transition from surgery to initiation of adjuvant chemotherapy. Based on current available evidence, there is no specific timing interval for the initiation of adjuvant chemotherapy in GC patients. Earlier initiation of adjuvant chemotherapy (<4 weeks) may not be mandatory for GC patients who underwent curative resection. However, the patients should be recommended to receive adjuvant chemotherapy within 6-8 weeks if their performance status and nutritional status were deemed to be appropriate. Minimizing postoperative complications and providing requisite nutritional advice may be helpful for timely initiation of adjuvant chemotherapy.

LncRNA MALAT1 Regulates the Cell Proliferation and Cisplatin Resistance in Gastric Cancer via PI3K/AKT Pathway

Background

Many studies showed that long non-coding RNA MALAT1 is served as an oncogene. However, the specific role of MALAT1 in gastric cancer is not fully elucidated. The aim of this study is to elucidate the regulatory effects of MALAT1 on tumor development and cisplatin resistance in gastric cancer.

Methods

TCGA database was applied to investigate the expression levels of MALAT1 in GC tissues and normal gastric tissues and its correlation with GC patients’ survival. Univariate and multivariate analysis were performed to investigate whether MALAT1 expression is an independent risk for overall survival of gastric cancer patients. The expression of MALAT1 was detected by Quantitative real-time PCR. After knockdown or overexpression of MALAT1, the cellular functions of GC cells were detected by cell-proliferation, flow cytometry, transwell assay and colony formation assays, respectively. Western blot analysis was performed to detect the protein levels of Bcl-2 and key genes in the PI3K/AKT pathway in GC cells. Finally, CCK-8 assay was performed to explore the effect of MALAT1 on cisplatin resistance of GC cells.

Results

Higher expression of MALAT1 was detected in GC tissues than that of adjacent normal tissues, high MALAT1 expression is an independent risk for overall survival of gastric cancer patients. Knockdown of MALAT1 inhibited proliferation, migration and invasion of GC cells, while overexpression of MALAT1 Overexpression of MALAT1 yielded opposite results. Western blot results showed that protein expressions of p-PI3K, p-AKT and p-STAT3 were downregulated after MALAT1 knockdown in GC cells, while these proteins were upregulated after MALAT1 overexpression. Additionally, the IC₅₀ in MGC803/CDDP cells transfected with si-MALAT1 was lower than in those transfected with si-NC. The apoptotic rate in MGC803 cells transfected with pcDNA-MALAT1 was remarkably lower than those transfected with NC.

Conclusion

We demonstrated that MALAT1 is highly expressed in GC, high MALAT1 expression is an independent risk factor for OS among GC patients. Moreover, MALAT1 promotes malignant progression of GC and contributes to cisplatin resistance of GC cells, indicating MALAT1 may serve as a biological hallmark for predicting the prognosis of GC.

Utilization of Minimally Invasive Surgery and Its Association with Chemotherapy for Locally Advanced Gastric Cancer

BACKGROUND

Minimally invasive surgery (MIS) is increasingly used to treat gastric cancer in the USA. A potential benefit of MIS is increased likelihood of receiving adjuvant chemotherapy. Our objectives were (1) to assess trends and predictors of MIS for gastric cancer, (2) to evaluate the association between MIS and postoperative chemotherapy, and (3) to investigate the relationship between MIS and survival.

METHODS

Patients with T3 or greater and/or N+ gastric adenocarcinoma were identified from the National Cancer Database from 2010 to 2015. Patients aged ≥ 85, with metastatic disease, treated with only preoperative chemotherapy, or with contraindications to chemotherapy were excluded. Hierarchical logistic regression and Cox proportional hazards were used to assess associations between MIS and postoperative chemotherapy and survival.

RESULTS

Of 21,872 gastric resections, 6083 (27.8%) were MIS and 15,789 (72.2%) open. The majority were partial/subtotal (68.3%). Utilization of MIS increased from 18 to 37% from 2010 to 2015 (p < 0.01). Predictors of MIS were Asian race, any insurance coverage, and treatment at high-volume centers. Among 7540 patients with locally advanced disease, MIS was associated with receiving postoperative chemotherapy compared to open surgery (77.7% vs. 71.9%; OR 1.31, 95% CI 1.11-1.54). MIS was associated with improved survival before adjusting for postoperative chemotherapy (HR 0.83; 95% CI 0.72-0.97) but not after (HR 0.87, 95% CI 0.75-1.01).

DISCUSSION

Utilization of MIS for locally advanced gastric cancer approximately doubled during the study period. Compared to open surgery patients, MIS patients were more likely to receive postoperative chemotherapy. The increased utilization of postoperative chemotherapy may explain the associated survival advantage observed with MIS.

Does three-dimensional surgery affect recurrence patterns in patients with gastric cancer after laparoscopic R0 gastrectomy? Results from a 3-year follow-up phase III trial

BACKGROUND

Numerous studies have shown that the short-term efficacy of three-dimensional (3D) laparoscopic radical gastrectomy (LG) is comparable to that of two-dimensional (2D)-LG. Whether 3D-LG affects the recurrence patterns of gastric cancer (GC) patients has not been investigated.

METHODS

From January 2015 to April 2016, a total of 419 patients were recruited for a phase III clinical trial (NCT02327481), which compared the short-term outcomes between the 2D and 3D groups. The long-term efficacy including recurrence patterns was compared between the 2D and 3D groups in this retrospective study. Multivariate analyses were performed to determine whether 3D-LG affects the recurrence patterns.

RESULTS

Ultimately, 401 patients were analyzed (197 in the 2D-LG group and 204 in the 3D-LG group), and no differences were observed in the clinicopathological data between the two groups. There were no significant differences between the two groups in the recurrence types, first recurrence time or recurrence-free survival (RFS) (all p > 0.05). According to the 7th American Joint Committee on Cancer tumor-node-metastasis (TNM) staging system, both groups were stratified into pathological stages I, II, and III. The stratified analysis showed no significant differences in RFS or overall survival (OS) among patients in each subgroup (all p > 0.05). The multivariate analysis of RFS showed that tumor diameter, pTNM stage, lymphovascular invasion, and adjuvant chemotherapy were independent factors (all p < 0.05). The multivariate analysis of post-recurrence survival (PRS) showed that adjuvant chemotherapy was an independent protective factor (p = 0.043).

CONCLUSIONS

3D-LG for GC did not differ significantly from 2D-LG in the effects on 3-year recurrence patterns, RFS and OS, which provides more tumor-related evidence for 3D technology. And due to the technological similarity, it may have certain reference value for robotic-assisted gastrectomy. Further multicenter, large-scale clinical trials are warranted.

Does neoadjuvant chemotherapy cancel out the negative survival impact induced by surgical complications after gastrectomy?

BACKGROUND

Postoperative infectious complications (ICs) are associated with a poor prognosis following gastric cancer surgery. Neoadjuvant chemotherapy (NAC) targeting scirrhous-type or bulky nodal disease reportedly exerts a prophylactic effect on the negative impact of ICs. However, a recent study clearly showed that NAC for scirrhous-type disease had no survival benefit. We investigated this prophylactic effect and significant interactions among subgroups of histological response, macroscopic type, and bulky nodal disease.

METHODS

We examined 115 patients who received NAC followed by radical gastrectomy between January 2008 and December 2015. The overall survival (OS) and disease-free survival (DFS) were compared between those with and without ICs. Our cohort included 62 with type 4/giant type 3, 44 with bulky nodal disease/para-aortic nodal disease, and 25 with other diseases.

RESULTS

A histological response was observed in 80 patients (69.5%). Thirty three (28.7%) developed ICs. There was no significant difference in the OS [hazard ratio (HR) 0.96; 95% confidence interval (CI) 0.47-1.99, p = 0.920] or DFS (HR 0.74; 95% CI 0.40-1.38, p = 0.342) by the presence of ICs. The HR was 1.00 in patients who had no response to NAC (grade 0/1a) and 0.95 in those who responded to NAC (grade 1b/2/3). No subgroups showed significant interactions for the OS.

CONCLUSIONS

NAC may cancel out the negative impact of morbidity on the survival in advanced gastric cancer patients. The prophylactic effects by NAC do not depend on the tumor type or histological response.

Impact of ypT, ypN, and Adjuvant Therapy on Survival in Gastric Cancer Patients Treated with Perioperative Chemotherapy and Radical Surgery

BACKGROUND

Perioperative chemotherapy and surgery is the standard of care in advanced gastroesophageal cancer patients, but its impact among those treated with radical surgery still needs further assessment. We present the results of this multimodality treatment approach in a gastric cancer patients cohort treated with D2 lymphadenectomy. We aimed to identify prognostic factors associated with improved survival.

PATIENTS AND METHODS

This retrospective cohort study enrolled patients treated with perioperative chemotherapy and resection in a single cancer center in Brazil between 2006 and 2016. Subjects presenting tumors of the gastric stump, esophageal tumors, or treated with intraperitoneal chemotherapy were excluded. Intention-to-treat survival analysis was performed for all subjects who started neoadjuvant chemotherapy, and prognostic factors were determined among those who had R0 resection.

RESULTS

This study included 239 patients, of whom 198 had R0 resection. The mean age was 59.9 years, and most had clinical stage IIB or III disease (88%). Among the 239 patients who started neoadjuvant chemotherapy, 207 (86.6%) completed all neoadjuvant treatment cycles, and surgical resection was performed in 225 subjects (94.1%). Overall 60-day morbidity and mortality rates were 35.6% and 4.4%, respectively. For the entire cohort, median survival was 78 months and the 5-year survival rate was 55.3%. Factors associated with worse survival were ypT3-4 stage, ypN + stage, extended resection, and no adjuvant chemotherapy.

CONCLUSIONS

Perioperative chemotherapy resulted in very good outcomes for patients treated with radical surgery, and downstaging after chemotherapy was shown to be a major determinant of prognosis.

Influence of Neoadjuvant Therapy on Poor Long-Term Outcomes of Postoperative Complications in Patients with Esophageal Squamous Cell Carcinoma: A Retrospective Cohort Study

BACKGROUND

Postoperative complications have a negative impact on overall survival after esophagectomy because systemic inflammation may induce residual cancer cell growth. A solution that could suppress micrometastasis is neoadjuvant therapy; however, to date, no study has shown that neoadjuvant therapy suppresses proliferation of cancer cells due to postoperative complications after esophagectomy. The aim of this study is to investigate the influence of neoadjuvant therapy on poor long-term outcomes of postoperative complications in patients with esophageal carcinoma.

PATIENTS AND METHODS

In total, 431 patients who underwent esophagectomy for esophageal squamous cell carcinoma were included in this study. We investigated the relationship between complications, such as pneumonia, and long-term oncologic outcomes with and without neoadjuvant therapy.

RESULTS

Among the patients, the 3-year overall survival (OS) rate was 69.5% and the disease-free survival (DFS) rate was 59.0%. The patients were categorized into two groups: the neoadjuvant therapy (+) group (n = 217) and neoadjuvant therapy (-) group (n = 214). Among patients not undergoing neoadjuvant therapy, patients with pneumonia or pyothorax had significantly poorer OS and DFS than patients without these complications. However, among patients undergoing neoadjuvant therapy, there were no significant differences in long-term outcomes, regardless of presence of complications. On multivariate analysis, pneumonia (p = 0.003), pyothorax (p < 0.001), and chylothorax (p = 0.002) were identified as predictors of death in the neoadjuvant therapy (-) group.

CONCLUSION

The negative impact of postoperative complications on long-term prognoses can be reduced by performing neoadjuvant therapy in patients with esophageal carcinoma.

Postoperative complications and prognosis after radical gastrectomy for gastric cancer: a systematic review and meta-analysis of observational studies

Background

Many observational studies have reported correlations between postoperative complications and prognosis after radical gastrectomy but the results are controversial. This meta-analysis was performed to investigate whether there is a correlation between postoperative complications and prognosis after radical gastrectomy.

Methods

Literature searches were performed in PubMed, EMBASE, and the Cochrane Library. Studies that investigated the correlations between any postoperative complications and prognosis after radical gastrectomy were included. The pooled hazard ratio (HR) with 95% confidence interval (CI) for postoperative complications regarding overall survival (OS) or recurrence-free survival (RFS) was calculated by using RevMan 5.3.5. Subgroup analyses were performed within pathological stages I, II, and III.

Results

Sixteen retrospective studies comprising 12,065 patients were included. The pooled HR (95% CI) for complications regarding OS was 1.79 (1.39, 2.30) and was 1.40 (1.06, 1.84) after excluding in-hospital mortality; the pooled HR (95% CI) for complications regarding RFS was 1.28 (1.10, 1.49). The pooled HR (95% CI) for infectious complications and leakage regarding OS was 1.86 (1.22, 2.83) and 2.02 (1.02, 4.00), respectively. The pooled HR (95% CI) for any reported postoperative complications regarding OS for stage I, II, and III diseases was 2.39 (0.77, 7.46), 4.35 (2.58, 7.35), and 2.84 (1.77, 4.56), respectively.

Conclusions

Postoperative complications correlate with poor prognosis after radical gastrectomy. Such correlations are found in stage II and III gastric cancer patients but remain to be determined in stage I gastric cancer patients.

Electronic supplementary material

The online version of this article (10.1186/s12957-019-1593-9) contains supplementary material, which is available to authorized users.

Preoperative Therapy for Gastric Adenocarcinoma is Protective for Poor Oncologic Outcomes in Patients with Complications After Gastrectomy

BACKGROUND

Postoperative complications (POC) are associated with poor oncologic outcomes in gastric cancer. We sought to evaluate the impact of POC on survival in patients with gastric cancer treated with upfront surgery (UpSurg) versus those treated with preoperative therapy (PreT).

METHODS

We analyzed data from a prospectively maintained database of patients who had undergone resection of their gastric cancer at our institution. Patients with T1N0 or M1 lesions, recurrent disease, and mortality within 90 days were excluded. Survival was compared between patients with and without POC in the UpSurg and PreT groups. Cox regression analyses were used to examine factors associated with overall survival (OS) and disease-free survival (DFS).

RESULTS

A total of 421 patients underwent resection of gastric cancer: 30% underwent upfront surgery, and 51% had a POC. Among patients who had POCs, 71% were infectious and 53% were Clavien-Dindo grade III or IV. UpSurg patients with a POC had shorter OS (5-year, 47 vs. 85%; p < 0.001) and DFS (5-year, 46 vs. 76%; p < 0.001) than those without a POC. In contrast, there was no difference in OS (5-year, 57 vs. 63%; p = 0.77) and DFS (5-year, 52 vs. 52%; p = 0.52) between PreT patients with and without POC. Multivariable Cox regression model demonstrated that a POC in UpSurg patients had significant impact on DFS (2.6 [95% confidence interval (CI) 1.48-4.74]), whereas it did not in PreT patients (0.9 [95% CI 0.70-1.33]).

CONCLUSIONS

The use of preoperative therapy negated the impact of POCs on OS and DFS in patients undergoing resection for gastric cancer.