Natural History of Gastric Cancer: Observational Study of Gastric Cancer Patients Not Treated During Follow-Up

Endoscopic submucosal dissection for early gastric cancer in a patient after left ventricular assist device implantation: A case report

The use of left ventricular assist device (LVAD) implantation has increased in recent years. Here, we report the first case of gastric endoscopic submucosal dissection (ESD) following LVAD implantation. A 69-year-old man who previously underwent LVAD implantation for severe heart failure underwent esophagogastroduodenoscopy, which revealed a 15-mm flat-elevated cancerous lesion at the greater curvature of the gastric angle. Before ESD, antithrombotic drugs were discontinued and replaced with 10,000 units of heparin. However, on the second day, the patient experienced dysarthria and right upper-extremity movement disorder despite a prothrombin time/international normalized ratio (PT-INR) of 2.01. On the fifth day, computed tomography revealed a low-density area extending from the left corona radiata to the basal ganglia, leading to a diagnosis of acute cerebral infarction. Aspirin and warfarin were immediately restarted, while the heparin infusion was discontinued after confirming recovery of PT activity. Thereafter, the neurological abnormalities did not aggravate and a trend toward symptomatic improvement was observed. Two months later, ESD was performed under continuous warfarin administration (PT-INR, 2.62) without heparin replacement, and the lesion was curatively resected without complications. The patient was discharged without adverse events. This case report provides useful information on the feasibility and perioperative management of ESD in patients with LVAD.

Prognosis of Elderly Patients with Gastric Cancer Treated with the Best Supportive Care

BACKGROUND

The prognosis of gastric cancer has gradually improved as treatments have evolved. However, curative treatments might be difficult when gastric cancer is detected in the elderly or individuals with multiple comorbidities. This study investigated the prognosis of elderly patients with gastric cancer who received best supportive care (BSC).

METHODS

This single-center observational study retrospectively reviewed medical records from elderly patients (>65 years-old) diagnosed with gastric cancer between 2014 and 2019 who received BSC.

RESULTS

Data were obtained from 39 patients with a median age of 90 years. Median follow-up period was 207 days. Median survival time for all causes was 508 days for stage 0, 1026 days for stage I, 319 days for stage II, 317 days for stage III, and 43 days for stage IV. Median survival time for cancer-specific deaths was 1987 days for stage 0, 1280 days for stage I, 331 days for stage II, 371 days for stage III, and 43 days for stage IV. Univariate analyses identified 'stage' and performance status as risk factors for both overall and cancer-specific mortality. In multivariate analyses, 'stage' was an independent risk factor predicting overall mortality (HR=3.71, 95%CI=1.73-7.98, P < 0.001) and both 'stage' and performance status were independent risk factors predicting cancer-specific mortality (HR=4.06 and 8.95, 95%CI=1.13-14.51 and 3.00-26.67, P = 0.031 and P < 0.001, respectively).

CONCLUSION

This result will help clarify the natural history of elderly patients with gastric cancer and provide useful information when choosing treatments in the future.

Risk stratification in gastric cancer lung metastasis: Utilizing an overall survival nomogram and comparing it with previous staging

BACKGROUND

Gastric cancer (GC) is prevalent and aggressive, especially when patients have distant lung metastases, which often places patients into advanced stages. By identifying prognostic variables for lung metastasis in GC patients, it may be possible to construct a good prediction model for both overall survival (OS) and the cumulative incidence prediction (CIP) plot of the tumour.

AIM

To investigate the predictors of GC with lung metastasis (GCLM) to produce nomograms for OS and generate CIP by using cancer-specific survival (CSS) data.

METHODS

Data from January 2000 to December 2020 involving 1652 patients with GCLM were obtained from the Surveillance, epidemiology, and end results program database. The major observational endpoint was OS; hence, patients were separated into training and validation groups. Correlation analysis determined various connections. Univariate and multivariate Cox analyses validated the independent predictive factors. Nomogram distinction and calibration were performed with the time-dependent area under the curve (AUC) and calibration curves. To evaluate the accuracy and clinical usefulness of the nomograms, decision curve analysis (DCA) was performed. The clinical utility of the novel prognostic model was compared to that of the 7th edition of the American Joint Committee on Cancer (AJCC) staging system by utilizing Net Reclassification Improvement (NRI) and Integrated Discrimination Improvement (IDI). Finally, the OS prognostic model and Cox-AJCC risk stratification model modified for the AJCC system were compared.

RESULTS

For the purpose of creating the OS nomogram, a CIP plot based on CSS was generated. Cox multivariate regression analysis identified eleven significant prognostic factors (P < 0.05) related to liver metastasis, bone metastasis, primary site, surgery, regional surgery, treatment sequence, chemotherapy, radiotherapy, positive lymph node count, N staging, and time from diagnosis to treatment. It was clear from the DCA (net benefit > 0), time-dependent ROC curve (training/validation set AUC > 0.7), and calibration curve (reliability slope closer to 45 degrees) results that the OS nomogram demonstrated a high level of predictive efficiency. The OS prediction model (New Model AUC = 0.83) also performed much better than the old Cox-AJCC model (AUC difference between the new model and the old model greater than 0) in terms of risk stratification (P < 0.0001) and verification using the IDI and NRI.

CONCLUSION

The OS nomogram for GCLM successfully predicts 1- and 3-year OS. Moreover, this approach can help to appropriately classify patients into high-risk and low-risk groups, thereby guiding treatment.

Personalizing age of gastric cancer screening based on comorbidity in China: Model estimates of benefits, affordability and cost-effectiveness optimization

The benefits of gastric cancer screening are related to age and comorbidity status, but reliable estimates are lacking in China. This study aimed to estimate the benefits and affordability of the gastric cancer screening strategy by level of comorbidity to inform decisions to screening age. We assessed six current gastric cancer screening strategies in China using a microsimulation model with different starting and stopping ages and comorbidity profiles, for a total of 378 strategies. 1,000,000 individuals were simulated in the model and followed the alternative strategies. Primary outcomes included gastric cancer incidence, the number of endoscopy and complications, life-years, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. Future costs and QALYs are discounted by 5% per year. Sensitivity analyses were used to evaluate model uncertainty. Strategies with longer screening durations were associated with higher benefits of life-year gained and gastric cancer deaths averted, but were also accompanied by a large number of endoscopy screening, and complication events. Using the threshold of US$18,575 per QALY gained, at the no, moderate, and severe comorbidity level, the leading cost-effectiveness strategies were the new gastric cancer screening scoring system strategy (NGCS) screening from age 40 years to 60 years (40-60), 40-55-NGCS, and 40-55-NGCS strategy, respectively. The results are robust in sensitivity analyses. Our study illustrates the importance of considering comorbidity conditions and age when determining the starting and stopping screening age for gastric cancer and informs the discussion on personalizing decisions. The trade-off between benefits and harms can also be referenced when necessary.

Impact of Coronavirus Disease 2019 on Gastric Cancer Diagnosis and Stage: A Single-Institute Study in South Korea

PURPOSE

Gastric cancer (GC) is among the most prevalent and fatal cancers worldwide. National cancer screening programs in countries with high incidences of this disease provide medical aid beneficiaries with free-of-charge screening involving upper endoscopy to detect early-stage GC. However, the coronavirus disease 2019 (COVID-19) pandemic has caused major disruptions to routine healthcare access. Thus, this study aimed to assess the impact of COVID-19 on the diagnosis, overall incidence, and stage distribution of GC.

MATERIALS AND METHODS

We identified patients in our hospital cancer registry who were diagnosed with GC between January 2018 and December 2021 and compared the cancer stage at diagnosis before and during the COVID-19 pandemic. Subgroup analyses were conducted according to age and sex. The years 2018 and 2019 were defined as the "before COVID" period, and the years 2020 and 2021 as the "during COVID" period.

RESULTS

Overall, 10,875 patients were evaluated; 6,535 and 4,340 patients were diagnosed before and during the COVID-19 period, respectively. The number of diagnoses was lower during the COVID-19 pandemic (189 patients/month vs. 264 patients/month) than before it. Notably, the proportion of patients with stages 3 or 4 GC in 2021 was higher among men and patients aged ≥40 years.

CONCLUSIONS

During the COVID-19 pandemic, the overall number of GC diagnoses decreased significantly in a single institute. Moreover, GCs were in more advanced stages at the time of diagnosis. Further studies are required to elucidate the relationship between the COVID-19 pandemic and the delay in the detection of GC worldwide.

Association of Metformin Treatment with Risk for Death in Diabetic Patients with Concomitant Gastric Cancer

IMPORTANCE

Despite the existing guideline's recommendation of metformin therapy as the initial approach for managing diabetes mellitus (DM), there remains a scarcity of comprehensive documentation regarding metformin's impact on outcomes that are important for patients.

OBJECTIVES

The objective of this study was to assess the potential impact of metformin treatment on the risk of death in individuals diagnosed with both gastric cancer and pre-existing diabetes mellitus (DM); Design, Setting, and Participants: The study made use of a dataset encompassing nationwide health insurance claims, allowing for a retrospective analysis of all patients with a history of gastric cancer diagnosis (classified under International Classification of Diseases 10th Revision code: C16.X) spanning from 1 January 2002 to 31 December 2012. The primary objective was to observe death within a 5-year follow-up period. The study population comprised 63,664 individuals who fell into two categories: those treated with metformin (n = 29,548) and those who did not receive metformin treatment (n = 34,116). This classification was based on the initial treatment allocation following the diagnosis of gastric cancer.

EXPOSURES

Metformin treatment, comorbidities, concurrent medication, and procedural information.

OUTCOMES

All-cause death, disease-specific death, cardiovascular death.

RESULTS

During the 5-year follow-up period, the metformin treatment group exhibited a lower cumulative incidence of all-cause death (27.5%) in comparison to the group not receiving metformin treatment (32.8%). Furthermore, the relative hazards for all-cause death were significantly reduced in the metformin treatment group (HR: 0.80, 95% CI 0.78-0.82), indicating a lower risk of death when compared to the non-metformin group. In addition, metformin treatment was associated with lower occurrences of disease-specific death (related to gastric cancer) and cardiovascular death when compared to the group not undergoing metformin treatment.

CONCLUSIONS

The findings demonstrated that the use of metformin was effective at improving prognosis among gastric cancer patients documented with prior DM. In this population-based cohort study, metformin treatment was associated with reduced risk of mortality.

Gastric Foveolar-type Adenocarcinoma with Raspberry-like Appearance in a Helicobacter pylori-uninfected Stomach: A Long-term Retrospective Follow-up of 16 Years

Esophagogastroduodenoscopy in a 58-year-old man revealed a protruding lesion measuring 6 mm in diameter in the fornix. An endoscopic biopsy of the lesion indicated well-differentiated adenocarcinoma. The lesion was resected by polypectomy. According to the Japanese histologic diagnostic criteria, we made a final diagnosis of early gastric cancer (U, Gre, 6×6 mm, Type 0-I, tub1, pT1a (M), pUl0, Ly0, V0, pHM0, pVM0). A retrospective review of the endoscopic images showed that this lesion had already been present in the images taken 16 years ago. The size and morphology of the lesion were the same as those of the first detected lesion.

The impact of early‐stage COVID‐19 pandemic on the diagnosis and treatment of gastric cancer: A cross‐sectional study using a large‐scale cancer registry in Hiroshima, Japan

Background

After the confirmation of coronavirus infection in Japan, a behavioral change caused people and physicians to refrain from visiting hospitals or undergoing examinations. This study aimed to assess how the trend of diagnosis in gastric cancers changed, and how it affected the therapeutic strategies and the interval from diagnosis to treatment during the COVID‐19 pandemic.

Methods

We use 15 cancer‐designated hospitals’ registries in Hiroshima, Japan. The target period was March to December 2020, and the same period in 2019 was set as the control period. The monthly mean of diagnoses and the interval from diagnosis to treatment were compared overall and separately by age, treatment procedure, diagnostic process, and clinical stage.

Result

In 2020, the monthly mean (standard deviation [SD]) of patients was 192.2 (29.9), a significant 20.1% decrease from 240.7 (20.7) in 2019 due to older age and curative treatment groups. By reason for performing endoscopy, the change rate in cancer screening, endoscopic follow‐up, and symptomatic status were ‐27.0%, ‐18.0%, and ‐17.3%, respectively. Meanwhile, the interval (days) from diagnosis to treatment (SD) was 37.8 (26.5) in 2020, significantly shorter than 46 (31.5) in 2019.

Conclusion

From 2019 to 2020, we observed a significant decrease in the diagnosis of curable early‐stage gastric cancer and treatments, although the interval from diagnosis to treatment decreased. This study suggests that cancer screening played a significant role in the decline in cancer diagnosis that occurred during the COVID‐19 pandemic. Even under COVID‐19 pandemic conditions, there should be an awareness of cancer screening and endoscopic follow‐up.

Prognostic and clinicopathological value of the geriatric nutritional risk index in gastric cancer: A meta-analysis of 5,834 patients

Background

Recent studies have explored the prognostic value of the geriatric nutritional risk index (GNRI) in patients with gastric cancer (GC), but the results are controversial. We aimed to systemically identify the association between the GNRI and prognosis in GC using a meta-analysis.

Methods

The databases of PubMed, Web of Science, Cochrane Library, and Embase were searched until September 25, 2022. Pooled hazard ratios and the corresponding 95% confidence intervals (CIs) were used to estimate the prognostic value of the GNRI in GC. Odds ratios (ORs) and 95% CIs were used to assess the correlation between the GNRI and clinicopathological characteristics of GC.

Results

Ten studies including 5,834 patients with GC were included in this meta-analysis. The merged results indicated that a low pretreatment GNRI was associated with inferior overall survival (hazard ratio = 1.21, 95% CI = 1.12-1.30, P < 0.001) and worse cancer-specific survival (hazard ratio = 2.21, 95% CI = 1.75-2.80, P < 0.001) for GC. Moreover, a low GNRI was significantly associated with an advanced pathological stage (OR = 2.27, 95% CI = 1.33-3.85, P = 0.003), presence of adjuvant chemotherapy (OR = 1.25, 95% CI = 1.01-1.55, P = 0.040), and tumor location in the lower stomach (OR = 1.33, 95% CI = 1.06-1.65, P = 0.012) in GC. However, there was no significant association between GNRI and sex, tumor differentiation, or lymph node metastasis in patients with GC.

Conclusion

Our meta-analysis identified that the pretreatment GNRI level was a significant prognostic factor for patients with GC. A low GNRI is associated with worse overall survival and inferior cancer-specific survival in patients with GC.

Endoscopic Submucosal Dissection for Early Gastric Cancer in Patients Aged 85 Years Old or Older Is Associated with a Good Prognosis Compared to Conservative Treatment without Any Invasive Procedure

INTRODUCTION

Studies have reported the feasibility of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) in elderly people with respect to both short- and long-term outcomes. As the elderly population in society increases, the requirement for managing super-elderly patients aged ≥85 years with EGC will also increase. This study aims to identify the long-term clinical outcomes of ESD for clinical T1N0 EGC in patients aged ≥85 years.

METHODS

A total of 370 consecutive patients aged ≥85 years with clinical T1N0 EGC who were managed in 11 institutions were reviewed retrospectively. On the basis of treatment strategy, we compared the overall survival (OS) and disease-specific survival (DSS) after performing propensity score-matched analysis between patients undergoing ESD (ESD group) and those not undergoing treatment (conservative treatment group). The potential prognostic factors were also investigated in the propensity score-matched patients.

RESULTS

After propensity score matching, we found that the 3-year OS and DSS rates were significantly higher in the ESD group than in the conservative treatment group (OS, 82.2% vs. 50.5%; p < 0.001; DSS, 100% vs. 80.1%; p = 0.008). Furthermore, ESD was identified as a significant factor for prolonged OS, whereas Charlson comorbidity index (CCI) ≥3 and prognostic nutritional index (PNI) <36.2 were associated with reduced OS.

CONCLUSION

ESD was associated with improved OS in patients with clinical T1N0 EGC aged ≥85 years compared with the absence of treatment. Furthermore, CCI and PNI were helpful for patient selection.

[Endoscopic Resection of Early Gastric Cancer in Elderly]

With the aging of the society, the proportion of elderly patients with gastric cancer is increasing and the chances of encountering elderly patients with early gastric cancer (EGC) are increasing. Because elderly patients have more comorbidities, and lower life expectancy than younger patients, the treatment strategy for elderly patients with EGC is not standardized. Therefore, it is necessary to identify risk factors related to survival of elderly patients with EGC and to establish treatment strategies according to prognosis in elderly patients with EGC.

Clinical Benefit and Cost Effectiveness of Risk-Stratified Gastric Cancer Screening Strategies in China: A Modeling Study

BACKGROUND AND OBJECTIVE

A new gastric cancer screening scoring system (NGCS) strategy was recommended for the early gastric cancer (GC) screening process in China. The current study aimed to assess the clinical benefits and the cost effectiveness of the NGCS strategy in GC high-risk areas of China from a societal perspective.

METHODS

A Markov microsimulation model was developed to evaluate 30 alternative screening strategies with varying initiation age, including the NGCS strategy, the modified NGCS strategy, and the endoscopic screening strategy with various screening intervals. The primary outcomes included GC mortality, number of endoscopies, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs). Cost estimates were reported in 2021 USD (US$) and both costs and benefits were discounted at 5% annually. Deterministic and probabilistic sensitivity analyses were performed to evaluate model uncertainty.

RESULTS

Screening with the NGCS strategy from age 40 years (40-NGCS) reduced the GC incidence by 86.4%, which provided the greatest benefit across strategies. Compared with all strategies, at a willingness-to pay threshold of US$17,922 per QALY, the 40-NGCS strategy was a leading cost-effective strategy, with an ICER of US$15,668 per QALY. Results were robust in univariate and probabilistic sensitivity analyses. The probability of the 40-NGCS strategy being cost effective was 0.863.

CONCLUSIONS

The 40-NGCS strategy was an effective and cost-effective strategy to reduce GC incidence and mortality in China. The findings provide important evidence for decision makers to formulate and optimize targeted approaches for GC prevention and control policies in China.

Effect of gastric cancer screening on long-term survival of gastric cancer patients: results of Korean national cancer screening program

BACKGROUND

Gastric cancer (GC) is the most common cancer type in Korea. Korean National Cancer Screening Program (KNCSP) offer either upper gastrointestinal series (UGIS) or upper endoscopy biennially for adults aged ≥ 40. This study aimed to investigate the effect of cancer screening program on the long-term survival among GC patients.

METHODS

A nationwide population-based cohort was constructed based on three national databases. Overall, 46,701 GC patients diagnosed in 2008 and 2009 were included in our final analysis, and they were followed-up until the end of 2019. Survival curves were estimated using the Kaplan-Meier analysis with the log-rank test. Cox proportional-hazards regression analysis was used to report the hazard ratios (HRs) with 95% confidence intervals.

RESULTS

A total of 18,614/46,701 (39.9%) patients died during the median follow-up time of 10.5 years. The survival rate was higher among screened patients (65.8%) than never-screened patients (49.1%). Screened patients had 53% (HR, 0.47; 95% CI 0.45-0.48) lower risk of death from GC. The HRs of GC-specific mortality was lower in upper endoscopy group (HR = 0.36; 95% CI = 0.34-0.37) compared with UGIS (HR = 0.69; 95% CI = 0.67-0.73). Screened patients within 2 years prior to cancer diagnosis had a 35% reduction in risk of GC death. The figure decline to approximately 19% among patients with interval time since last screening of > 3 years.

CONCLUSIONS

Our findings emphasized the positive effects of GC screening on long-term GC patient survival. Also, patients screened by upper endoscopy or within 2 years before diagnosis had the best survival outcomes.

A Pilot Study of Prognostic Value of Metastatic Lymph Node Count and Size in Patients with Different Stages of Gastric Carcinoma

Background

The correlation between the preoperative lymph node count (LNC) on multidetector computed tomography (MDCT) and the prognosis of gastric carcinoma (GC) remains to be defined. This research aims to evaluate the prognostic value of LNC on MDCT in GC patients based on tumor-node-metastasis (TNM) staging, using different size criteria for counting.

Methods

The clinical data of 126 patients with gastric adenocarcinoma undergoing gastrectomy were retrospectively analyzed. Lymph nodes greater than 8mm and 5mm on MDCT were counted and recorded. The prognostic implications of LNC on MDCT for patient survival were analyzed according to different size criteria for counting and tumor TNM staging.

Results

When 8mm was used as the counting criterion, LNC on MDCT had no significant effect on the overall survival (OS) of the entire cohort. In addition, the OS of T1–T2 GC patients with LNC on MDCT ≥1 was significantly worse than that of patients with LNC on MDCT <1. When 5mm was used as the counting criterion, LNC on MDCT was found to be significantly associated with the OS of the entire cohort. In the subgroup analysis, patients with relatively advanced (T3-T4, N+ and III) GC with LNC on MDCT >7 showed a significantly worse OS than those with LNC on MDCT ≤7. LNC on MDCT >7 with 5mm as the counting criterion and Stage III were independent risk factors for adverse prognosis.

Conclusion

The prognostic value of LNC on MDCT based on different size criteria varies in patients with different stages of GC. LNC of a smaller size (5mm) on MDCT may be a prognostic factor for patients with relatively advanced GC.

Long-term outcomes after endoscopic resection for late-elderly patients with early gastric cancer

BACKGROUND AND AIMS

With the population aging, the incidence of early gastric cancer (EGC) is increasing. We aimed to clarify the indications for endoscopic resection (ER) in late-elderly patients with EGC in terms of life expectancy.

METHODS

Patients aged ≥75 years who underwent ER for EGC at our institution from January 2007 to December 2012 were enrolled. Clinical data, including Eastern Cooperative Oncology Group performance status (ECOG-PS), Charlson comorbidity index, and Prognostic Nutritional Index (PNI), were collected at the time of ER. Overall survival (OS) was the main outcome measure.

RESULTS

Four hundred consecutive patients were enrolled. Mean patient age was 79.3 years (range, 75-93). The 5-year follow-up rate was 89.0% (median follow-up period, 5.6 years). Five-year OS was 80.8% (95% confidence interval [CI], 76.4-84.4), and 5-year net survival standardized for age, sex, and calendar year was 1.09 (95% CI, 1.03-1.15). With a multivariate analysis, ECOG-PS 2 to 4 (hazard ratio, 8.84; 95% CI, 3.07-25.4), PNI <49.1 (hazard ratio, 2.49; 95% CI, 1.53-4.06), and eCura C-2 (hazard ratio, 1.79; 95% CI, 1.11-2.88) were independent prognostic factors. When none of these factors was met, the 5-year OS rate was 90.4% (95% CI, 84.0-94.3).

CONCLUSIONS

ER for EGC in late-elderly patients may improve life expectancy. ER is recommended in patients with a good ECOG-PS and PNI and in whom ER is expected to be non-eCura C-2.

Gastric adenocarcinoma arising from hamartomatous inverted polyp during 8‐year follow‐up

Gastric hamartomatous inverted polyp (GHIP) is rare, with few reports of carcinogenesis from GHIP during long‐term follow‐up. A 51‐year‐old woman was diagnosed as having a submucosal tumor (SMT) during esophagogastroduodenoscopy (EGD) in 2008. In 2016, although the size and height of the lesion had not changed, she was referred to our hospital for further investigation of the lesion. EGD depicted a gastric SMT of 20 mm in diameter in the greater curvature of the upper gastric body, and a biopsy specimen showed a well to poorly differentiated adenocarcinoma. Following successful laparoscopic total gastrectomy, histopathological examination revealed an intramucosal adenocarcinoma arising in GHIP.

Age Cutoff and Yield of Prompt Esophagogastroduodenoscopy to Detect Malignancy in Vietnamese with Upper Gastrointestinal Symptoms: An Endoscopic Database Review of 472,744 Patients from 2014 to 2019

BACKGROUND AND AIMS

Age cutoff is an important factor in deciding whether esophagogastroduodenoscopy (EGD) is necessary for patients presenting with upper gastrointestinal symptoms. However, the cutoff value is significantly different across populations. We aimed to determine the age cutoff for EGD that assures a low rate of missing upper gastrointestinal malignancy (UGIM) and to assess the yield of prompt EGD in Vietnamese patients presenting with upper gastrointestinal symptoms.

METHODS

All EGDs performed in outpatients during a 6-year period (2014-2019) at a tertiary hospital that provided an open-access endoscopy service were retrospectively reviewed. Repeat or surveillance EGDs were excluded. Different age cutoffs were evaluated in terms of their prediction of the absence of UGIM. The yield of endoscopy to detect one malignancy (YoE) was also calculated.

RESULTS

Of 472,744 outpatients presenting with upper gastrointestinal symptoms, there were 2198 (0.4%) patients with UGIM. The median age and male-to-female ratio of patients with UGIMs were 57.9 ± 12.5 years and 2.5 : 1, respectively. The YoEs in patients <40, 40-60, and >60 years of age were <1, 1-10, and >10 per 1000 EGDs, respectively. The age cutoffs of 30 years in females and 35 years in males could detect 98.2% (95% CI: 97.7%-98.8%) of UGIM cases with a YoE of about 1 per 1000 EGDs.

CONCLUSIONS

The age cutoff for EGD in Vietnamese should be lower than that recommended by current international guidelines. The strategy of prompt EGD showed a low YoE, and its cost-effectiveness requires further investigation.

Gastric Xanthoma Is Related to the Rapid Growth of Gastric Cancer

Early detection of gastric cancer is important. However, rapid growth of gastric cancers that cannot be resected endoscopically occurs even with periodic check-ups. Accordingly, we assessed factors associated with the speed of gastric cancer growth by examining historical endoscopic images. A total of 1996 gastric cancer cases were screened, and characteristics of lesions with slow and rapid growth were assessed. A total of 114 lesions from 114 patients were included in the assessment. Sixty slow-growing and fifty-four rapidly growing gastric cancers were compared. Female sex and incidence of lesions in the lower part of the stomach were significantly less frequent in the rapid-growth group than in the slow-growth group. History of endoscopic treatment tended to be more frequent in the rapid-growth group. Age, body mass index, histology, Helicobacter pylori status, and medications did not differ significantly between groups. Xanthoma was significantly related to rapid growth of gastric cancer, and map-like redness tended to be more frequent in the rapid-growth group in univariate analysis. Xanthoma was significantly related to rapid growth of gastric cancer on multivariate analysis. Further studies are warranted to clarify the pathophysiological mechanisms involved in the speed of gastric cancer growth.

Screening and surveillance for gastric cancer: Does family history play an important role in shaping our strategy?

Family history is an important risk factor of gastric cancer. No guidelines have been developed that target gastric cancer with a family history; only hereditary familial gastric cancer is targeted. We review the available evidence regarding the familial aggregation mechanisms of gastric cancer and a strategy of screening and surveillance for gastric cancer in individuals with a positive family history of the disease. As there is a synergic effect of Helicobacter pylori infection and family history on the increased risk of gastric cancer, Helicobacter pylori eradication should be considered in all infected individuals with a family history of gastric cancer. Currently, there is weak evidence indicating that suitable timing to initiate eradication therapy is at the age of 20, when precancerous lesions, including significant gastric atrophy and intestinal metaplasia, have not been established. Reasonable timing to initiate screening for gastric cancer in individuals with a family history of gastric cancer is 10 years prior to the age of onset of gastric cancer in affected relatives. A 2-year surveillance interval, instead of the 3-year interval recommended in the present guidelines, may be better to detect early gastric cancer in those individuals who have already developed precancerous gastric lesions.

Tumor Doubling Time Using CT Volumetric Segmentation in Metastatic Adrenocortical Carcinoma

Adrenocortical carcinoma (ACC) is a rare malignancy with an overall unfavorable prognosis. Clinicians treating patients with ACC have noted accelerated growth in metastatic liver lesions that requires rapid intervention compared to other metastatic locations. This study measured and compared the growth rates of metastatic ACC lesions in the lungs, liver, and lymph nodes using volumetric segmentation. A total of 12 patients with metastatic ACC (six male; six female) were selected based on their medical history. Computer tomography (CT) exams were retrospectively reviewed and a sampling of ≤5 metastatic lesions per organ were selected for evaluation. Lesions in the liver, lung, and lymph nodes were measured and evaluated by volumetric segmentation. Statistical analyses were performed to compare the volumetric growth rates of the lesions in each organ system. In this cohort, 5/12 had liver lesions, 7/12 had lung lesions, and 5/12 had lymph node lesions. A total of 92 lesions were evaluated and segmented for lesion volumetry. The volume doubling time per organ system was 27 days in the liver, 90 days in the lungs, and 95 days in the lymph nodes. In this series of 12 patients with metastatic ACC, liver lesions showed a faster growth rate than lung or lymph node lesions.

Analysis of Progression Time in Pancreatic Cancer including Carcinoma In Situ Based on Magnetic Resonance Cholangiopancreatography Findings

BACKGROUND

Pancreatic cancer (PC) exhibits extremely rapid growth; however, it remains largely unknown whether the early stages of PC also exhibit rapid growth speed equivalent to advanced PC. This study aimed to investigate the natural history of early PCs through retrospectively assessing pre-diagnostic images.

METHODS

We examined the data of nine patients, including three patients with carcinoma in situ (CIS), who had undergone magnetic resonance cholangiopancreatography (MRCP) to detect solitary main pancreatic duct (MPD) stenosis >1 year before definitive PC diagnosis. We retrospectively analyzed the time to diagnosis and first-time tumor detection from the estimated time point of first-time MPD stenosis detection without tumor lesion.

RESULTS

The median tumor size at diagnosis and the first-time tumor detection size were 14 and 7.5 mm, respectively. The median time to diagnosis and first-time tumor detection were 26 and 49 months, respectively.

CONCLUSIONS

No studies have investigated the PC history, especially that of early PCs, including CIS, based on the initial detection of MPD stenosis using MRCP. Assessment of a small number of patients showed that the time to progression can take several years in the early PC stages. Understanding this natural history is very important in the clinical setting.

[Impact of COVID-19 on oncological surgery of the upper gastrointestinal tract]

BACKGROUND

The outbreak of the coronavirus disease 2019 (COVID-19) pandemic imposed limitations for elective surgery, impacting the associated hospital standards worldwide. As certain treatment windows must be adhered to in oncological surgery, the limited intensive care unit (ICU) capacity had to be critically distributed in order to do justice to both acutely ill and oncology patients. This manuscript summarizes the impact of COVID-19 on the management of oncological surgery of the upper gastrointestinal tract and particularly esophageal surgery in German medical centers.

MATERIAL AND METHODS

A survey of German centers for esophageal surgery was performed on the impact of COVID-19 on operative management for esophageal surgery during the first lockdown. After inspection, assessment, critical analysis and interpretation, the results were compared to the international literature.

RESULTS AND DISCUSSION

Initial recommendations of international societies warned for caution and restraint regarding interventions of the upper gastrointestinal tract that were not absolutely necessary. Oncological surgery should be performed under strict restrictions, especially only after negative testing for COVID-19 and only with sufficiently available personal protective equipment for the personnel. Furthermore, minimally invasive procedures were preferably not recommended. In diseases with alternative treatment options, such as definitive chemoradiotherapy of esophageal squamous cell carcinoma, these should be given priority when possible. In the further development of the pandemic, it was shown that due to a high standardization of preoperative management, postoperative results comparable to pre-pandemic times could be achieved particularly with respect to the diagnostics of infections.

Predictive Factors for Short-Term Survival after Non-Curative Endoscopic Submucosal Dissection for Early Gastric Cancer

BACKGROUND/AIMS

For early gastric cancer (EGC) treated using endoscopic submucosal dissection (ESD) with poor curability defined by the Japanese Guidelines (non-curative EGC, N-EGC), additional gastrectomy has been recommended. However, N-EGC patients without additional gastrectomy often die of other diseases within a relatively short interval after ESD. It has been unclear whether additional gastrectomy is beneficial or not for such patients. The aim of this study was to clarify predictors for short-term survival of N-EGC patients without additional gastrectomy after ESD.

METHODS

One hundred six N-EGC patients without additional gastrectomy were included in this study. Factors related to short-term survival, defined as death within 3 years after ESD, were evaluated using uni- and multivariate analyses by comparing patients with and without short-term survival (Groups S and C, respectively).

RESULTS

During the mean follow-up period of 89 months, 39 patients died (14 patients died within 3 years, being Group S). The cause of death was gastric cancer for only 1 patient in the Group C. The 3- and 5-year overall survival rates were 86.8 and 81.8%, respectively, and the 3- and 5-years disease-specific survival rates were 100 and 98.9%, respectively. Univariate analyses showed that short-term survival was statistically associated with elevated morphology, high-risk status for lymph node metastases as defined by the eCura system, severe comorbidity (Charlson Comorbidity Index [CCI] ≥3), low level of activity in daily living (being unable to go out by oneself), habitation (a nursing home), and several poor nutritional prognostic indices (neutrophil to lymphocyte ratio ≥2.5, geriatric nutritional risk index <92, C-reactive protein ≥1.0). In the multivariate analysis, a high CCI (≥3) was the independent predictor for short-term survival after ESD (odds ratio, 8.1; 95% confidence interval, 1.53-43.0; p = 0.014).

CONCLUSIONS

Severe comorbidity indicated by a high CCI score (≥3) was the independent predictor for short-term survival for EGC patients without additional gastrectomy after non-curative ESD. Since the cause of death for most patients was not gastric cancer, observational follow-ups without additional gastrectomy might be a reasonable option for patients with a poor general status indicated by a CCI ≥3.

Prognostic role of tumour-infiltrating lymphocytes assessed by H&E-stained section in gastric cancer: a systematic review and meta-analysis

OBJECTIVES

Some studies have identified tumour-infiltrating lymphocytes (TILs) in H&E-stained sections of gastric cancer, but the prognostic and clinicopathological significance of this remains unclear. The objective of this study is to evaluate the associations between H&E-based TIL density and prognosis and clinicopathological characteristics of patients with gastric cancer.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Cochrane Library, PubMed and Embase databases were searched through 25 February 2020.

ELIGIBILITY CRITERIA

Studies evaluating the correlations between TILs assessed by H&E-stained sections and prognosis and clinicopathological characteristics of gastric cancer were included.

DATA EXTRACTION AND SYNTHESIS

Relevant data were extracted and risks of bias were assessed independently by two reviewers. HR and relative risk (RR) with 95% CI were pooled by random-effect models to estimate the associations between TIL density and overall survival (OS) and clinicopathological characteristics, respectively.

RESULTS

We enrolled nine studies including 2835 cases for the present meta-analysis. High TILs were associated with superior OS (HR=0.68, 95% CI 0.52 to 0.87, p=0.003) compared with low TILs. High TILs were significantly associated with lower depth of invasion (T3-T4 vs T1-T2) (RR=0.58, 95% CI 0.50 to 0.66, p<0.001), less lymph node involvement (presence vs absence) (RR=0.68, 95% CI 0.56 to 0.81, p<0.001) and earlier TNM (tumour, node, metastasis) stage (III-IV vs I-II) (RR=0.68, 95% CI 0.55 to 0.83, p<0.001). TIL density was not associated with age, gender, Lauren classification or histological grade. The methodology for evaluating TIL and its cut-off value varied across different studies, which might affect the results of our meta-analysis.

CONCLUSIONS

Our meta-analysis suggests that H&E-based TIL density is a reliable biomarker to predict the clinical outcomes of patients with gastric cancer. Multicentre, prospective studies are needed to further confirm our findings.

PROSPERO REGISTRATION NUMBER

CRD42020169877.

Treatment strategies for gastric cancer during the COVID-19 pandemic

The coronavirus disease 2019 pandemic has become a major global public health problem. Governments are taking the necessary steps to reduce the movement of people to contain the spread of the virus. However, these measures have caused considerable distress to patients with gastric cancer who are newly diagnosed or are undergoing treatment. In addition to the cancer, they must deal with longer waiting times for surgery and poor communication with doctors. Furthermore, gastric cancer patients generally have low immunity and a poor nutritional status, so they are a high-risk group for infection with the novel coronavirus. Therefore, it is necessary to formulate reasonable outpatient management strategies to reduce the adverse effects of the pandemic on their treatment. We summarize the management strategies for patients with gastric cancer during the pandemic.

Treatment of Gastric Cancer Patients During COVID-19 Pandemic: The West is More Vulnerable

The outbreak of the COVID-19 is currently the biggest international concern. Treatment of gastric cancer (GC) patients in the pandemic era with high hospital burden and under severe oncological/surgical resource constraints should implicate a need for resource re-allocation with a new "pandemic" GC treatment algorithm. The neoadjuvant/perioperative (radio-)chemotherapy is applied in the majority of advanced GC cases with poor postoperative therapy compliance. In the East, radical surgery is frequently used in the first instance, with adjuvant chemotherapy reserved for patients with a high risk of recurrence. Moreover, the elderly population might be effectively treated by surgery alone, thus saving oncological resources for younger people who need a more aggressive approach. In this framework, prioritization is a key concept based on the severity of symptoms and the need for urgent (surgical) intervention. High-risk and marginally effective surgery should be replaced with definitive radio- and/or chemotherapy. The pandemic framework to provide optimal care for GC patients must be based on multidisciplinary decision-making and include all anti-cancer treatment options: surgery, systemic therapy, and radiotherapy. The priority and staffing dictate adherence to the new algorithm. We believe that these priorities may improve the delivery of care to all, including elderly GC patients.

Strategy for the practice of digestive and oncological surgery during the Covid-19 epidemic

The Covid-19 pandemic is changing the organization of healthcare and has a direct impact on digestive surgery. Healthcare priorities and circuits are being modified. Emergency surgery is still a priority. Functional surgery is to be deferred. Laparoscopic surgery must follow strict rules so as not to expose healthcare professionals (HCPs) to added risk. The question looms large in cancer surgery-go ahead or defer? There is probably an added risk due to the pandemic that must be balanced against the risk incurred by deferring surgery. For each type of cancer-colon, pancreas, oesogastric, hepatocellular carcinoma-morbidity and mortality rates are stated and compared with the oncological risk incurred by deferring surgery and/or the tumour doubling time. Strategies can be proposed based on this comparison. For colonic cancers T1-2, N0, it is advisable to defer surgery. For advanced colonic lesions, it seems judicious to undertake neoadjuvant chemotherapy and then wait. For rectal cancers T3-4 and/or N+, chemoradiotherapy is indicated, short radiotherapy must be discussed (followed by a waiting period) to reduce time of exposure in the hospital and to prevent infections. Most complex surgery with high morbidity and mortality-oesogastric, hepatic or pancreatic-is most often best deferred.

Prevention and control strategies of general surgeons under COVID-19 pandemic

The novel coronavirus SARS-CoV-2 and the disease caused by it, COVID-19, have spread to virtually all countries worldwide within just a few months. The economic and sanitary impact has been enormous. In March 2020, the World Health Organization declared COVID-19 a pandemic. How to effectively prevent and control SARS-CoV-2 transmission while providing care to surgical patients during the pandemic is a crucial topic. In order to minimize the risk of cross-infection between patients and physicians, many hospitals have taken measures to limit outpatient services, elective hospitalizations, and the number of operations. Based on the prevention and control measures stipulated by major medical institutions in China, this overview provides recommendations for surgeons from three aspects: outpatient treatment, ward management and perioperative protection. Telemedicine should be encouraged as a means of social distancing. Outpatient examination should be selected. Reasonable spatial arrangement and effective environmental disinfection are important for ward management. Patient selection for surgery and timing of operations should be carefully discussed within multi-disciplinary teams. Appropriate personal protective equipment should be worn adapted to the situational risk. On December 31, 2019, China reported to the WHO Country Office a pneumonia of unknown cause detected in Wuhan [1], [3]. Subsequently, the disease later named COVID-19 affected a substantial proportion of the population in Wuhan and spread to other areas of China. Relying on a nationwide shutdown and mandatory quarantine, China has effectively curtailed the domestic outbreak. However, due to the high transmissibility of SARS-Cov-2 and the mobility of people, COVID-19 spread to the rest of the world. Many hospitals worldwide were faced with confirmed and suspected SARS-Cov-2 infections, putting a huge strain on the safety of patients and employees. Consequently, surgical patients who seek medical care during the COVID-19 pandemic present significant challenges. This paper summarizes medical care and infection prevention and control in general surgery patients during the COVID-19, pandemic in the light of the current situation in China. It provides reference for surgeons and decision makers in health care in other countries suffering from the COVID-19 pandemic.

[Strategy for the practice of digestive and oncologic surgery in COVID-19 epidemic situation]

La pandémie due au COVID-19 modifie l’organisation des soins et change la réalisation de la chirurgie digestive. Les priorités sanitaires et les circuits de soins sont modifiés. La chirurgie d’urgence reste prioritaire. Les interventions pour chirurgie fonctionnelles sont à reporter. La chirurgie par laparoscopie doit suivre des règles strictes pour ne pas exposer les professionnels à un surrisque. Le questionnement principal concerne la chirurgie oncologique, opérer ou reporter ? Il existe probablement un sur risque opératoire induit par la pandémie qui doit être mis en balance avec le retard de prise en charge chirurgical. Pour chaque type de cancer, colon, pancréas, œsogastrique, hépatocarcinome, la morbi-mortalité est rappelée et mise en parallèle avec le risque oncologique lié au retard à la chirurgie et/ou au temps de doublement de la tumeur. Cette comparaison permet de proposer des stratégies, ainsi pour les cancers coliques (T1-2, N0), il est souhaitable de retarder la chirurgie. Pour les lésions coliques avancées, il semble prudent de recommander une chimiothérapie néo adjuvante et d’attendre. Pour les cancers du rectum T3-4 et/ou N+, une radio-chimiothérapie est indiquée, une radiothérapie courte devra être discutée (suivie d’une période d’attente) afin de réduire le temps d’exposition à l’hôpital et d’éviter les infections. La majorité des chirurgies complexes à forte morbi-mortalité, œsogastrique, hépatique ou pancréatique doivent sans doute le plus souvent être reportée.