Long-Term Outcomes of Pylorus-Preserving Gastrectomy for Early Gastric Cancer

BACKGROUND

In the short term, pylorus-preserving gastrectomy (PPG) has been reported to have advantages over distal gastrectomy (DG) with regard to postprandial symptoms and dumping syndrome. We aimed to evaluate the quality of life after PPG for early gastric cancer in the long term in comparison to that after DG.

METHODS

Twenty-six patients who underwent gastrectomy (11 PPG, 15 DG) for early gastric cancer at Osaka University Hospital participated and were followed for more than 4 years. Body weight changes, nutritional status, dual-phase scintigraphy findings, endoscopic survey results, and questionnaire responses after gastrectomy were examined.

RESULTS

There were significantly lower ratios of weight changes in PPG than in DG, 5 years after surgery. There were no differences in the clinicopathological characteristics, nutritional parameters, questionnaire responses, and endoscopic findings between the two groups. Based on gastric scintigraphy, although the gastric emptying of liquids showed similar curves in the two groups, gastric emptying of solids was significantly slower in the PPG group than in the DG group (P = .039).

DISCUSSION

PPG had advantages with regard to long-term outcomes over DG in terms of weight maintenance and the prevention of rapid gastric emptying. PPG might be efficient in patients with early gastric cancer.

Effects of postoperative oral elemental nutritional supplement on skeletal muscle loss after gastrectomy for gastric cancer

BACKGROUND

We previously showed that daily nutritional intervention with an oral elemental diet (ED) at 300 kcal/day for 6-8 weeks postoperatively decreased the percentage of body weight loss (%BWL), and that the effect was maintained for 1 year. This post hoc analysis aimed to determine whether this intervention decreased skeletal muscle mass loss 1-year post-gastrectomy.

METHODS

Data from consecutive, untreated patients with histopathologically confirmed stage I-III gastric adenocarcinoma who planned to undergo total gastrectomy (TG) or distal gastrectomy (DG) and were enrolled in a previously published randomized trial were used. The primary endpoint was the percentage of skeletal muscle mass index (%SMI) loss from baseline at 1 year postoperatively, based on abdominal computed tomography images obtained preoperatively and at 1 year postoperatively.

RESULTS

The overall median %SMI loss was lower in the ED versus control group, but the difference was not significant. The difference in %SMI loss in the ED and control groups was greater in patients with TG (10.1 vs. 13.0; P = 0.12) than in those with DG (5.5 vs. 6.8; P = 0.69). A correlation was observed between %BWL and %SMI loss in both groups (ED group, coefficient 0.591; control group, coefficient 0.644; P < 0.001 for both). Type of gastrectomy (coefficient 7.38; P = 0.001) and disease stage (coefficient - 6.43; P = 0.04) were independent predictors of postoperative skeletal muscle mass loss.

CONCLUSION

ED administration for 6-8 weeks following gastrectomy had no inhibitory effect on skeletal muscle loss at 1 year postoperatively.

CLINICAL TRIAL REGISTRATION

UMIN000023455.

A comprehensive study on non-cancer-related mortality risk factors in elderly gastric cancer patients post-curative surgery

BACKGROUND

The increasing incidence of gastric cancer in the elderly underscores the need for an in-depth understanding of the challenges and risks associated with surgical interventions in this demographic. This study aims to investigate the risk factors and prognostic indicators for non-cancer-related mortality following curative surgery in elderly gastric cancer patients.

METHODS

This retrospective analysis examined 684 patients with pathological Stage I-III gastric cancer who underwent curative resection between January 2012 and December 2021. The study focused on patients aged 70 years and above, evaluating various clinical and pathological variables. Univariate analysis was utilized to identify potential risk factors with to non-cancer-related mortality and to access prognostic outcomes.

RESULTS

Out of the initial 684 patients, 244 elderly patients were included in the analysis, with 33 succumbing to non-cancer-related causes. Univariate analysis identified advanced age (≥ 80 years), low body mass index (BMI) (< 18.5), high Charlson Comorbidity Index (CCI), and the presence of overall surgical complications as significant potential risk factors for non-cancer related mortality. These factors also correlated with poorer overall survival and prognosis. The most common cause of non-cancer-related deaths were respiratory issues and heart failure.

CONCLUSION

In elderly gastric cancer patients, managing advanced age, low BMI, high CCI, and minimizing postoperative complications are essential for reducing non-cancer-related mortality following curative surgery.

Phase II study of S-1 plus docetaxel as first-line treatment for older patients with advanced gastric cancer (OGSG 0902)

BACKGROUND

Although there is insufficient evidence for the treatment of older patients with advanced gastric cancer, fluorouracil combined with platinum chemotherapy has been recognized as a standard first-line treatment for such populations in Japan despite the lack of efficacy and toxicity data.

METHODS

Patients aged 75 years or older with advanced gastric cancer were enrolled. S-1 plus docetaxel (docetaxel: 40 mg/m2, day 1; S-1: 80 mg/m2, days 1-14; q21 days) was repeated every 3 weeks. The primary endpoint was overall response rate. Secondary endpoints were safety, progression-free survival, time to treatment failure, and overall survival. The sample size was calculated as 30 under the hypothesis of an expected response rate of 40% and a threshold response rate of 20%, at a power of 90% and a two-sided alpha value of 5%.

RESULTS

From February 2010 to January 2015, 31 patients were enrolled and assessed for efficacy and toxicity. The response rate was 45.2% (95% CI 27.3%-64.0%; p = 0.001) and it exceeded the expected response rate set at 40%. Median progression-free survival was 5.8 months, the 1-year survival rate was 58.1%, and the median survival time was 16.1 months. The major grade 3/4 adverse events were neutropenia (58%), febrile neutropenia (13%), anemia (10%), anorexia (10%), and fatigue (6%).

CONCLUSIONS

These findings indicate that S-1 plus docetaxel as first-line treatment for older patients is feasible and that it has promising efficacy against advanced gastric cancer.

Portal vein wedge resection and patch venoplasty with autologous vein grafts for hepatobiliary-pancreatic cancer

BACKGROUND

Advanced hepatobiliary-pancreatic cancer often invades critical blood vessels, including the portal vein (PV) and hepatic artery. Resection with tumor-free resection margins is crucial to achieving a favorable prognosis in these patients. Herein, we present our cases and surgical techniques for PV wedge resection with patch venoplasty using autologous vein grafts during surgery for pancreatic ductal adenocarcinoma (PDAC) and perihilar cholangiocarcinoma (PhCC).

CASE PRESENTATION

Case 1: 73-year-old female patient with PDAC; underwent subtotal stomach-preserving pancreatoduodenectomy, with superior mesenteric vein wedge resection and venoplasty with the right gonadal vein. Case 2: 67-year-old male patient with PDAC; underwent distal pancreatectomy and celiac axis resection, with PV wedge resection and venoplasty with the middle colic vein. Case 3: 51-year-old female patient with type IV PhCC; underwent left hepatectomy with caudate lobectomy and bile duct resection, with hilar PV wedge resection and venoplasty with the inferior mesenteric vein (IMV). Case 4: 69-year-old male patient with type IIIA PhCC; underwent right hepatopancreatoduodenectomy, with hilar PV resection and patch venoplasty with the IMV. All patients survived for over 12 months after the surgery, without local recurrence.

CONCLUSIONS

PV wedge resection and patch venoplasty is a useful technique for obtaining tumor-free margins in surgeries for hepatobiliary-pancreatic cancer.

A distal ileum malignant peripheral nerve sheath tumour after abdominal radiation therapy: case report of a rare tumour

Malignant peripheral nerve sheath tumours (MPNSTs) are malignant tumours arising from a peripheral nerve or displaying nerve sheath differentiation. Most MPNSTs are found on the head, body trunk and extremities, whereas cases in the gastrointestinal are extremely rare. About half arise in neurofibromatosis type 1 patients and 10% arise post-irradiation. This is probably the first small bowel MPNST post-radiation therapy case reported. A 72-year-old female who received radiotherapy 30 years ago for cervical cancer was admitted with progressive abdominal pain and weight loss. Computed tomography revealed a mass with inhomogeneous enhancement in the lumen of the small intestine. Tumour excision was performed with ileocecal and sigmoid colon resection due to suspicion for peripheral tissue invasion. Histopathological examination revealed spindle-shaped cells with focal cartilage differentiation. Together with immunochemistry stain showing complete loss of H3K27me3, a final diagnosis of MPNST was made. The patient is presently under regular follow-ups, and has remained disease-free for 24 months.

A rare intrahepatic splenosis mimicking hepatocellular carcinoma: A case report

Intrahepatic splenosis (IHS) is a rare disease that is considered to result from heterotopic autotransplantation or implantation of splenic tissue after splenic trauma or surgery. A 46-year-old man with a treatment history of a left lateral liver segmentectomy and splenectomy for a road traffic injury 30 years earlier presented to Sakai City Medical Center (Sakai, Japan) with acute abdominal pain in November 2019. Physical examination showed no significant signs, and serum data were normal. Computed tomography revealed a hypodense mass measuring 2.5x1.7 cm in segment 7 of the liver. Gadoxetic acid-enhanced magnetic resonance imaging showed early enhancement in the arterial phase and washout in the delayed phase. Therefore, laparoscopic surgery was performed with a preoperative diagnosis of hepatocellular carcinoma. Pathological examination of the tumor showed IHS. The postoperative course was uneventful, and the patient developed no new abnormal region in the liver during 2 years of follow-up. The present study presented a case of IHS assumed to be hepatocellular carcinoma. IHS should be considered as a differential diagnosis of a liver mass detected years after splenic trauma or surgery, even in cases with imaging patterns suggesting malignancy.

Meta-analysis of three randomized trials of capecitabine plus cisplatin (XP) versus S-1 plus cisplatin (SP) as first-line treatment for advanced gastric cancer

BACKGROUND

S-1 plus cisplatin (SP) and capecitabine plus cisplatin (XP) are standard first-line regimens for advanced gastric cancer (AGC) worldwide. We conducted a meta-analysis using individual participant data (IPD) to investigate which is more suitable.

METHODS

IPD from three randomized trials were collected. In these trials, patients with AGC were randomly allocated to SP (S-1 80-120 mg for 21 days plus cisplatin 60 mg/m2 (q5w)) or XP (capecitabine 2000 mg/m2 for 14 days plus cisplatin 80 mg/m2 (q3w)).

RESULTS

In 211 eligible patients, median overall survival (OS) for SP versus XP was 13.5 and 11.7 months (hazard ratio [HR], 0.787; p = 0.114), progression-free survival (PFS) was 6.2 and 5.1 months (HR, 0.767; P = 0.076), and TTF was 5.1 and 4.0 months (HR, 0.611; P = 0.001). The most common grade ≥ 3 adverse events with SP or XP were neutropenia (18% vs. 29%) and anorexia (16% vs.18%). Subgroup analysis demonstrated significant interaction between treatment effect and performance status > 1 (HR, 0.685; P = 0.036), measurable lesion (HR, 0.709; P = 0.049), primary upper third tumor (HR, 0.539; P = 0.040), and differentiated type (HR, 0.549; interaction, 0.236; P = 0.019). For the differentiated type, OS was significantly longer in the SP group (13.2 months) than in the XP group (11.1 months) (HR, 0.549; P = 0.019). For the undifferentiated type, OS was similar in the SP group (14.2 months) and in the XP group (12.4 months) (HR, 0.868; P = 0.476).

CONCLUSIONS

SP and XP were both effective and well tolerated. SP might be suitable for the pathological differentiated subtype of AGC.

CLINICAL TRIAL REGISTRATION

The HERBIS-2, HERBIS-4A, and XParTS II trials were registered with UMIN-CTR as UMIN000006105, UMIN000006755, and UMIN000006045, respectively.

A Multicenter, Phase II Trial of Schedule Modification for Nab-Paclitaxel in Combination with Ramucirumab for Patients with Previously Treated Advanced Gastric or Gastroesophageal Junction Cancer: The B-RAX Trial (JACCRO GC-09)

BACKGROUND

This study investigated whether schedule modification of bi-weekly nanoparticle albumin-bound paclitaxel (nab-PTX) plus ramucirumab (RAM) is efficacious against gastric cancer (GC) or gastroesophageal junction cancer (GJC).

PATIENTS AND METHODS

Patients with unresectable GC or GJC who were previously treated with fluoropyrimidine-containing regimens received nab-PTX (100 mg/m²) on days 1, 8, and 15 and RAM (8 mg/kg) on days 1 and 15 of a 28-day cycle. Based on the incidence of severe adverse events (AEs) during the first cycle, patients were modified to bi-weekly therapy from the second cycle. The primary endpoint was progression-free survival (PFS) in the bi-weekly therapy population. Based on the hypothesis that bi-weekly nab-PTX plus RAM would improve PFS from 4.5 to 7.0 months, 40 patients were required for power of 0.8 with a one-sided α of 0.05.

RESULTS

Of the 81 patients enrolled, 47 patients (58%) were assigned to bi-weekly therapy. Patient characteristics were Eastern Cooperative Oncology Group performance status of 1 (19%) and diffuse type (45%). Median PFS was 4.7 months (95% confidence interval [CI] 3.7-5.6 months) and overall response rate was 25% (95% CI 11-39%). Severe AEs of grade 3 or worse were mainly neutropenia (83%) and hypertension (23%). EQ-5D scores were maintained during the treatment. In patients who continued standard-schedule therapy, median PFS was 2.7 months (95% CI 1.8-4.0 months).

CONCLUSIONS

The primary endpoint for PFS was statistically not met, but modification of nab-PTX plus RAM to a bi-weekly schedule might be a feasible treatment option as second-line treatment for advanced GC/GJC patients, especially elderly patients, with severe AEs during the first cycle.

Minimizing invasiveness and simplifying the surgical procedure for upper and middle early gastric cancer with near-infrared light and organ traction

BACKGROUND

Surgeons are often faced with optimal resection extent and reconstructive method problems in laparoscopic gastrectomy for gastric cancer in the upper and middle body of the stomach. Indocyanine green (ICG) marking and Billroth I (B-I) reconstruction were used to solve these problems with the organ retraction technique.

CASE PRESENTATION

A 51-year-old man with upper gastrointestinal endoscopy revealed a 0-IIc lesion in the posterior wall of the upper and middle gastric body 4 cm from the esophagogastric junction. Clinical T1bN0M0 (clinical stage IA) was the preoperative diagnosis. Laparoscopic distal gastrectomy (LDG) and D1 + lymphadenectomy was decided to be performed considering postoperative gastric function preservation. The ICG fluorescence method was used to determine the accurate tumor location since the determination was expected to be difficult to the extent of optimal resection with intraoperative findings. By mobilizing and rotating the stomach, the tumor in the posterior wall was fixed in the lesser curvature, and as large a residual stomach as possible was secured in gastrectomy. Finally, delta anastomosis was performed after increasing gastric and duodenal mobility sufficiently. Operation time was 234 min and intraoperative blood loss was 5 ml. The patient was allowed to be discharged on postoperative day 6 without complications.

CONCLUSION

The indication for LDG and B-I reconstruction can be expanded to cases where laparoscopic total gastrectomy or LDG and Roux-en-Y reconstruction has been selected for early-stage gastric cancer in the upper gastric body by combining preoperative ICG markings and gastric rotation method dissection.

[Successful Treatment with TACE and RFA for a Hepatocellular Carcinoma Case with Lung Metastasis]

We report a hepatocellular carcinoma(HCC)case with lung metastasis that was successfully treated with transarterial chemoembolization(TACE)and percutaneous radiofrequency ablation(RFA). A man in his 60s took right robe liver resection for HCC after TACE for its rupture. Lung metastasis occurred at S1+2 and S6 in the left lung, and an adverse event interrupted standard molecular target therapies. Because extrahepatic metastasis had been seen only in these two locations for a long time, TACE was performed for both metastases. The feeders for both lesions were each intercostal artery, and controlling the drug inflow was necessary to avoid drug influx into the spinal cord branches when S6 metastasis was treated. The viable lesion remained in the S6 lesion, so RFA was added for both lung metastases. 100% tumor necrosis has been observed since the RFA.

[A Case Report of Stage Ⅳb Thoracic Esophageal Cancer Responding to Multidisciplinary Treatment]

A 68-year-old man was referred to our hospital because of back pain during swallowing. Upper gastrointestinal endoscopy revealed a lower esophageal type 3 tumor. The patient was diagnosed with esophageal squamous cell carcinoma by the biopsy specimen. CT scan showed thoracic lower esophagus wall thickening, left paracardiac lymph node swelling, and a low-density area in the liver. Therefore, the patient was diagnosed with Stage Ⅳb esophageal cancer. After introducing cisplatin plus 5-FU combination therapy, the liver metastasis disappeared. After 9 chemotherapy courses, the patient received radical chemoradiotherapy. After completing chemoradiotherapy, the patient was followed up without any treatment. After 3 years since the treatment initiation, the patient is surviving without any relapse.

[Case of Robot-Assisted Low Anterior Resection with Total Cystectomy for Rectal Cancer Invading the Urinary Bladder/Prostate in Collaboration with Urologists]

We present a case of a 72-year-old man diagnosed with rectal cancer invading the urinary bladder/prostate. Preoperative chemoradiotherapy substantially reduced the tumor size. In collaboration with urologists, robot-assisted low anterior resection with total cystectomy was performed using the da Vinci Xi system. Depending on the surgical situation, the colorectal surgeon and urologist could smoothly and rapidly play the role of a console surgeon. Although the first robot-assisted multi-organ resection of our institution, the surgery was completed safely without any complications. Although the patient developed urinary tract infection postoperatively, he recovered and was discharged after postoperative 23 days. In conclusion, robot-assisted surgery would be useful in pelvic surgery involving multiple departments such as colorectal surgery, urology, and gynecology.

Histology Classification Highlights Differences in Efficacy of S-1 versus Capecitabine, in Combination with Cisplatin, for HER2-Negative Unresectable Advanced or Recurrent Gastric Cancer with Measurable Disease

It has been suggested that the therapeutic efficacy of S-1 + cisplatin (SP) and capecitabine + cisplatin (XP) may differ depending on the histology of the tumor, but no clear evidence exists. Individual participant data were obtained from three randomized phase II trials in which such patients received either SP (S-1 [40-60 mg twice daily for 21 days] plus cisplatin [60 mg/m² on day 8], every 5 weeks) or XP (capecitabine [1000 mg/m² twice daily for 14 days] plus cisplatin [80 mg/m² on day 1], every 3 weeks). A total of 162 patients were included, with 79 patients in the SP arm and 83 patients in the XP arm. Although there was also no difference between arms in ORR according to histological classification, differentiated tumors showed a significantly better OS (but not PFS) for SP versus XP that was associated with a deeper tumor shrinkage. Undifferentiated tumors showed a consistently better OS, and PFS for SP versus XP, likely because cases without tumor shrinkage tended to be fewer for SP. Our data thus showed that SP was superior to XP in this setting, but there were qualitative differences in therapeutic efficacy dependent on tumor histology.

Effects of perioperative eicosapentaenoic acid‑enriched oral nutritional supplement on the long‑term oncological outcomes after total gastrectomy for gastric cancer

Basic and clinical reports have suggested that eicosapentaenoic acid (EPA) exhibits anti-tumor activity. The present study evaluated whether perioperative EPA could improve the survival of patients with localized gastric cancer as a key secondary endpoint of a randomized clinical study. The present study was designed as multicenter, open-label, superiority, randomized trial to confirm the preventive effect of EPA on body weight loss after total gastrectomy for gastric cancer. Eligible patients were randomized to either the standard-diet group (EPA-off group) or EPA-on group by a centralized dynamic method. An EPA-enriched supplement (ProSure^®) was given to the EPA-on group in addition to their standard diet. This supplement included 600 kcal with 2.2 g/day of EPA. Among the 126 patients who were randomized, 123 patients (EPA-off group, n=60; EPA-on group, n=63) were examined in the survival analyses. All background factors were well balanced between the two groups. The 3-year and 5-year overall survival rates were 74.6 and 67.8%, respectively, in the EPA-off group, and 77.8 and 76.2% in the EPA-on group. There was no significant difference between the EPA-off and EPA-on groups (hazard ratio, 0.77; P=0.424). In the subgroup analysis, the hazard ratio was 0.39 in patients who received neoadjuvant chemotherapy and 0.57 in patients with nodal metastasis. In conclusion, a clear survival benefit of perioperative EPA was not observed in localized gastric cancer. The value of EPA should be further tested in a future study in patients with unfavorable advanced gastric cancer. Clinical trial number: UMIN000006380; date of registration, September 21, 2011.

[A Case of Palliative Abdominoperineal Resection and Perineal Reconstruction by Gluteus Maximus Flap following Regrowth of Primary Anal Canal Cancer with the Perianal Skin Infiltration after CRT]

An 85-year-old woman who visited the hospital with sores on the perianal skin was diagnosed with squamous cell carcinoma of the anal canal(cT3N1aM0, cStage ⅢC). She received chemoradiotherapy(radiation total 54 Gy/30 Fr, mitomycin C/capecitabine). The tumor initially shrank, but regrowth of the primary lesion, extensive perianal skin infiltration, and the appearance of para aortic lymph node metastases was observed 6 months later. Laparoscopic abdominoperineal resection was performed to mitigate strong local symptoms. The perineal defect was repaired with bilateral gluteus maximus flap(V- Y flap). The operation prevented anal pain and improved ADL. The patient is currently undergoing chemotherapy 7 months after surgery. We report the case with a review of the literature in which ADL was improved by salvage surgery for tumor regrowth with severe local symptoms and distant metastases after chemoradiotherapy for squamous cell carcinoma of the anal canal.

A phase Ⅱ, non-randomized, prospective trial of biweekly nab-paclitaxel in combination with ramucirumab for patients with previously treated advanced gastric or gastroesophageal junction cancer: B-RAX trial (JACCRO GC-09)

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Background: The combination of paclitaxel (PTX) plus ramucirumab (RAM) has been the standard regimen for advanced gastric cancer (GC) or gastro-esophageal junction cancer (GJC) patients (pts) who were treated with fluoropyrimidine-containing regimen. In a phase 2 trial, it was showen that nab-PTX plus RAM has promising activity (objective response rate [ORR], 55 %; median progression free survival [PFS], 7.6 months) [Bando H, et al. Eur J Cancer 2018] and is, therefore, a treatment option. However, high incidence of myelosuppression led to discontinuation of the nab-PTX. Therefore, we conducted this study to investigate whether schedule modification to biweekly nab-PTX plus RAM therapy is safe and effective. Methods: Pts with GC or GJC treated with fluoropyrimidine-containing regimen were enrolled and received nab-PTX (100 mg/m2) on days 1, 8, and 15 and RAM (8 mg/kg) on days 1 and 15 of a 28-day cycle. The treatment schedule of pts with severe myelosuppression during the first cycle was modified to biweekly therapy from the second cycle. The primary endpoint was PFS in modified pts. Secondary endpoints included ORR, disease control rate (DCR), overall survival (OS), and safety. The exploratory analysis evaluated PFS and OS in pts who continued standard-schedule therapy. Based on the hypothesis that biweekly nab-PTX plus RAM therapy would improve PFS from 4.5 months to 7.0 months, 40 pts were required for a power of 0.8 with a one-sided α of 0.05. Results: Of the 81 pts who were enrolled, 76 pts received standard nab-PTX plus RAM in the first cycle and 47 pts (58%) were modified to the bi-weekly therapy. Pts characteristics in the modified pts were as follows: median age, 70 years; male, 72%; ECOG PS 0, 81%; and poorly differentiated adenocarcinoma or signet ring cell carcinoma, 45%. The median relative dose intensities of the entire period and after modification were 66% and 60%, respectively. In the modified pts, median PFS was 4.7 months (95% Confidence Interval [CI]: 3.7–5.6), median OS was 13.9 months (95% CI: 9.1–16.9), ORR was 25% (95% CI: 11–39), and DCR was 75% (95% CI: 61–89). Tumor shrinkage was observed in 61% of the pts (n = 36) with measurable lesion. In pts who could continue standard-schedule therapy, median PFS was 2.7 months (95% CI: 1.8–4.0) and median OS was 8.0 months (95% CI: 5.6–14.7). Severe (Grade >3) adverse events after modification were neutropenia (55%), anemia (13%), hypertension (17%), and peripheral sensory neuropathy (13%). Conclusions: Our study could not meet the primary endpoint for PFS. However, PFS in pts with standard-schedule therapy was numerically lower than that in the modified pts. The modification to biweekly schedule might be considered to be a treatment option for GC/GJC pts with severe myelosuppression in second-line nab-PTX plus RAM therapy. Clinical trial information: jRCTs031180061.

Effects of an oral elemental nutritional supplement in gastric cancer patients with adjuvant S-1 chemotherapy after gastrectomy: A multicenter, open-label, single-arm, prospective phase II study (OGSG1108)

AIM

Post-surgical weight loss influences chemotherapy compliance and may be a risk factor for survival. Intake of an oral elemental nutritional supplement (OENS) can reduce weight loss after gastric cancer (GC) surgery. We assessed whether therapy completion levels would increase in patients receiving postoperative adjuvant chemotherapy in combination with an OENS.

METHODS

This was a multicenter, open-label, single-arm, phase II study in GC patients who underwent curative total or distal gastrectomy (TG/DG) and received adjuvant S-1 chemotherapy. The primary endpoint was the S-1 completion rate for 1 year with a relative performance (RP) value of ≥70%; secondary endpoints included factors affecting the completion rate of S-1, RP value after eight S-1 courses, S-1 and OENS persistence rates, nutritional index, OENS compliance, and safety.

RESULTS

In 71 efficacy-evaluable patients, the S-1 completion rate was 69.0% (TG, 68.0%; DG, 69.6%) and the RP value was 87.5 (TG, 89.1; DG, 87.5). Over eight treatment courses, median persistence rates were 89.0% for S-1 and 93.8% for the OENS. The mean OENS compliance was 81.8% at the fourth S-1 course and 52.9% at the eighth course. The incidence of Grade 3 or 4 adverse events was 27.2%, most commonly neutropenia (12.3%).

CONCLUSIONS

The completion rate of S-1 for 1 year in patients who could take the OENS exceeded the pre-defined threshold level. Randomized controlled trials are warranted to confirm the role of OENS in adjuvant chemotherapy.

Hybrid approach with laparoscopic wall-inversion surgery and single-incision intragastric surgery for intraluminal gastrointestinal stromal tumor: A case report

Laparoscopic wedge resection (LWR) for intraluminal gastrointestinal stromal tumor (GIST) leads to excessive resection of normal gastric wall. We report a case of GIST around the cardia successfully treated with full-thickness partial resection using a hybrid approach of laparoscopic surgery and single-incision intragastric surgery (SIIGS). A 69-year-old woman had a 5 cm intraluminal GIST at the posterior wall around the cardia. Submucosal injection of glycerin and indigo carmine was performed with transoral endoscopy. Circumferential seromuscular incision followed by placement of seromuscular sutures to invert the lesion into the stomach was performed under laparoscopy. By SIIGS, resection of the inverted mucosa and retrieval of the tumor were completed. A hybrid approach consisting of laparoscopic wall-inversion surgery and SIIGS was useful for intraluminal GIST and may expand the indications for laparoscopic wall-inversion surgery by removing size limitations.

Randomized phase II study of CPT-11 versus PTX versus each combination chemotherapy with S-1 for advanced gastric cancer that is refractory to S-1 or S-1 plus CDDP: OGSG0701

BACKGROUND

To compare irinotecan-alone, paclitaxel-alone, and each combination chemotherapy with S-1 in patients with advanced gastric cancer (AGC) that is refractory to S-1 or S-1 plus cisplatin (SP).

METHODS

Patients with AGC after first-line chemotherapy with S-1 or SP, or patients during adjuvant chemotherapy or within 26 weeks after adjuvant chemotherapy completion with S-1 with confirmed disease progression were eligible. Patients were randomly divided into four groups based on treatment: irinotecan-alone (irinotecan; 150 mg/m², day 1, q14 days), paclitaxel-alone (paclitaxel; 80 mg/m², days 1, 8, 15, q28 days), S-1 plus irinotecan (irinotecan; 80 mg/m², days 1, 15, S-1; 80 mg/m², days 1-21, q35 days), and S-1 plus paclitaxel (paclitaxel; 50 mg/m², day1, 8, S-1; 80 mg/m², days 1-14, q21 days). The primary endpoint was overall survival (OS) and secondary endpoints were progression-free survival (PFS), response rate, and safety.

RESULTS

From July 2008 to March 2012, 127 patients were enrolled. No difference in median OS was observed in the irinotecan vs. paclitaxel groups or in the monotherapy groups vs. the S-1 combination therapy groups. Median PFS was longer in the paclitaxel group compared with the irinotecan group (4.1 vs. 3.6 months, p = 0.035), although no difference was observed when comparing monotherapy vs. S-1 combination. The most common grade 3 to 4 hematological adverse events were neutropenia with no difference in incidence rate across the treatment groups.

CONCLUSIONS

There was no difference in OS between irinotecan and paclitaxel no in OS prolongation of S-1 combination therapy in second-line chemotherapy.

Phase 1 study of the liposomal formulation of eribulin (E7389-LF): Results from the advanced gastric cancer expansion cohort

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Background: Eribulin has proven efficacy in previously treated metastatic breast cancer and liposarcoma. E7389-LF is a new formulation that uses liposomes to encapsulate eribulin, which is anticipated to improve eribulin concentration in tumor tissues. In the dose-expansion part of a phase 1 study of E7389-LF, the safety profile was acceptable and 2 patients (pts) out of 10 with gastric cancer (GC) had an objective response. Thus, the GC cohort was expanded for further evaluation. Here, we report efficacy and safety data from the phase 1 expansion cohort of pts with advanced GC who were treated with E7389-LF. Methods: Eligible pts were those with GC who had no alternative standard or effective therapy options after ≥2 prior chemotherapy regimens. Target total enrollment was 32 pts (10 pts in the initial GC cohort plus an additional 22 pts in the expanded cohort). E7389-LF 2.0 mg/m2 was administered intravenously once every 3 weeks. Tumor responses were assessed every 6 weeks (± 1 week) by RECIST v1.1. Results: At data cutoff (Oct 16, 2020), 34 pts with GC were enrolled (10 pts in the initial GC cohort; 24 pts in the expanded GC cohort) with a median of 5 prior therapies (range, 2–11). Previous immune checkpoint inhibitor (ICI) therapy was reported for 26 (76.5%) pts. All pts were evaluable for objective response rate (ORR) and progression-free survival (PFS), and 30 pts were evaluable for overall survival (OS). Among all pts with GC, the ORR was 17.6% (95% CI 6.8–34.5) and the disease control rate was 79.4% (95% CI 62.1–91.3). Median PFS was 3.7 months (95% CI 2.7–4.3) and median OS was 7.6 months (95% CI 6.7–15.4). The ORRs were 19.2% (95% CI 6.6–39.4) in ICI-pretreated pts and 12.5% (95% CI 0.3–52.7) in pts without prior ICI therapy. Median PFS was similar regardless of prior treatment with ICIs (3.7 months [95% CI 2.7–5.6] in ICI-pretreated pts vs 3.4 months [95% CI 1.0–4.3] in pts without prior ICI therapy); however, the PFS rate at 6 months in ICI-pretreated pts was higher vs the rate in pts without prior ICI therapy (35.9% [95% CI 17.2–55.1] vs 0%, respectively). Median OS was also longer in ICI-pretreated pts (evaluable pts, n = 23) vs pts without prior ICI therapy (evaluable pts, n = 7) (10.0 months [95% CI 6.7–not estimable] vs 6.7 months [95% CI 3.1–8.5], respectively). Common grade ≥3 adverse events included neutropenia (41.2%), leukopenia (29.4%), and anemia (26.5%). In cycle 1, there were no cases of febrile neutropenia among the 22 pts treated with prophylactic peg-GCSF; among pts who did not receive prophylactic peg-GCSF, 16.7% of pts had febrile neutropenia. Conclusions: E7389-LF had a manageable safety profile and encouraging activity in pts with heavily treated GC. In pts with GC, prior treatment with ICIs might enhance the potential efficacy of E7389-LF. These results support further development of E7389-LF for advanced GC. Clinical trial information: NCT03207672.

Impact of preoperative chemotherapy as initial treatment for advanced gastric cancer with peritoneal metastasis limited to positive peritoneal lavage cytology (CY1) or localized peritoneal metastasis (P1a): a multi-institutional retrospective study

BACKGROUND

Gastric cancer (GC) patients with peritoneal metastasis are defined as stage IV in the Japanese classification of GC. For patients with peritoneal metastasis limited to positive peritoneal lavage cytology (CY1) and/or localized peritoneal metastasis (P1a), gastrectomy followed by S1 monotherapy is one of the most widely accepted therapeutic strategy in Japan. This study investigated the efficacy of preoperative chemotherapy as initial treatment in GC patients with CY1 and/or P1a.

METHODS

We retrospectively reviewed GC patients diagnosed with CY1 and/or P1a at 34 institutions in Japan between 2008 and 2012. Selection criteria were: adenocarcinoma, no distant metastasis except CY1 or P1a, and no prior treatment. The subjects were divided into an Initial-Chemotherapy group and an Initial-Surgery group, according to the initial treatment.

RESULTS

A total of 824 patients were collected and 713 eligible patients were identified for this study. As the initial treatment, 150 patients received chemotherapy (Initial-Cx), and 563 patients underwent surgery (Initial-Sx). Initial-Cx regimens were cisplatin plus S1/docetaxel plus cisplatin plus S1/others (n = 90/37/23). Both overall survival (OS) and progression-free survival (PFS) were similar between the Initial-Cx and Initial-Sx groups (median OS 24.8 and 24.0 months, HR 1.07, 95% CI 0.87-1.3; median PFS 14.9 and 13.9 months, HR 1.04, 95% CI 0.85-1.27). The 5-year OS rates were 22.3% in the Initial-Cx group and 21.5% in the Initial-Sx group.

CONCLUSIONS

Although, the preoperative chemotherapy did not show a survival benefit for GC patients with CY1 and/or P1a, initial-Cx showed favorable survival in patients who converted to P0 and CY0.

Retrograde endoscopic submucosal dissection for early thoracic esophageal carcinoma

Although the standard treatment for intramucosal esophageal cancer without lymph node metastasis is endoscopic submucosal dissection (ESD), we sometimes encounter patients who are not able to undergo a transoral endoscopic examination. Here, we report a surgical procedure consisting of transgastric retrograde ESD to treat early esophageal cancer (T1a-EP, N0, M0) because of a stricture after hypopharyngeal cancer surgery. This retrograde ESD procedure can be a safe and effective treatment option for early esophageal cancer. This is the first report of a surgical retrograde ESD method for esophageal cancer.

Safety and activity of trifluridine/tipiracil and ramucirumab in previously treated advanced gastric cancer: an open-label, single-arm, phase 2 trial

BACKGROUND

Findings of preclinical and clinical trials in colorectal cancer have shown promising antitumour effects of the co-formulation trifluridine/tipiracil and VEGF inhibition. We aimed to investigate the safety and activity of trifluridine/tipiracil and ramucirumab for previously treated advanced gastric cancer.

METHODS

We did an open-label, single-arm, two-cohort, phase 2 study at eight centres in Japan. We enrolled patients with unresectable advanced gastric cancer or gastro-oesophageal junction adenocarcinoma. Cohort A included patients previously treated with one line of chemotherapy without ramucirumab and cohort B included patients previously treated with two to four lines of chemotherapy, including ramucirumab. Patients received trifluridine/tipiracil (35 mg/m2) orally twice daily on days 1-5 and days 8-12 of each 28-day treatment cycle, plus intravenous ramucirumab (8 mg/kg) on days 1 and 15. The primary endpoint was the disease control rate, assessed by investigators and defined as the proportion of patients with a confirmed best overall response, according to Response Evaluation Criteria in Solid Tumors version 1.1. This trial is registered on JapicCTI (JapicCTI-194596) and is ongoing but not recruiting.

FINDINGS

Between April 8 and Oct 11, 2019, 64 patients were enrolled and included in the safety and activity analyses, 33 in cohort A and 31 in cohort B. In cohort A, the disease control rate was 85% (95% CI 68-95; 28 of 33 patients) and in cohort B it was 77% (59-90; 24 of 31 patients). Common treatment-related adverse events of grade 3 or worse were neutrophil count decreased (27 [82%] in cohort A and 23 [74%] in cohort B), white blood cell count decreased (eight [24%] and seven [23%]), and platelet count decreased (eight [24%] and four [13%]). Serious treatment-related adverse events were recorded in three patients in cohort A (fatigue and neutrophil count decreased; large intestine perforation; and febrile neutropenia, platelet count decreased, and anaemia). No patients in cohort B had a serious treatment-related adverse event, and no treatment-related deaths were reported in either cohort.

INTERPRETATION

Trifluridine/tipiracil and ramucirumab showed an acceptable safety profile and clinical activity in patients with previously treated advanced gastric cancer regardless of previous ramucirumab exposure.

FUNDING

Taiho Pharmaceutical and Eli Lilly.

Impact of frailty on super elderly patients with peripheral artery disease from the I-PAD 3 year registry

Background

Unlike age, frailty is often not taken into account in treatment indications of Endovascular treatment (EVT). One of the reason is that there was little known the relationship between frailty and the outcome of EVT for super elderly patients with peripheral artery disease (PAD). We investigate impacts of frailty on the super elderly patient prognosis who underwent EVT.

Purpose

To investigate impacts of frailty on the super elderly patient prognosis who underwent EVT.

Methods

From August 2015 to July 2016, 335 consecutive patients who underwent EVT were enrolled in the I-PAD registry from 7 institutes in Nagano prefecture. Among them, we selected and analyzed 91 super elderly PAD patients (≥80 years-old) and divided them into two groups:those with moderate or higher frailty (Clinical Frailty Scale (CFS) ≥6, n=28) and those without (CFS ≤5, n=63). The primary endpoints were cardiovascular death and major adverse cardiovascular and limb events (MACLE), defined as a composite of cardiovascular death, myocardial infarction, stroke, admission for heart failure, major amputation and revascularization.

Results

The median follow-up period was 2.7 years. Freedom rate from cardiovascular death and MACLE were significantly lower among patients with moderate or higher frailty than among those without (47.0% vs. 58.0%, P=0.03; 39.1% vs. 68.5%, P&lt;0.01).

Conclusion

The prognosis of super elderly patients with moderate or higher frailty is worse than those without.

Funding Acknowledgement

Type of funding source: None

Short-term and long-term outcomes of laparoscopic colectomy with multivisceral resection for surgical T4b colon cancer: Comparison with open colectomy

AIM

In response to the rising use of laparoscopic surgery, recent studies have shown that laparoscopic multivisceral resections for locally advanced colon cancer are safe, feasible, and provide acceptable oncological outcomes. However, the usefulness of laparoscopic multivisceral resection remains controversial. Here, we aimed to compare short-term and long-term outcomes between laparoscopic and open multivisceral resection approaches for treating locally advanced colon cancer.

METHODS

We retrospectively collected data on 1315 consecutive patients admitted to the National Hospital Organization, Osaka National Hospital, for surgical treatment of colorectal cancer between 2010 and 2017. We assessed invasiveness in terms of operating times, blood loss, and complications. Oncological outcomes included 5-year survival rates and recurrences.

RESULTS

We included 85 patients that underwent a colectomy with a multivisceral resection for locally advanced colon cancer; of these, 38 were treated with a laparoscopic approach and 47 were treated with an open approach. Compared to the open surgery group, the laparoscopic group had significantly less blood loss (median volume: 25 vs 140 mL, P <0.001), a lower complication rate (10.5% vs 29.8%, P = 0.036), and shorter hospital stays (12 vs 15 days, P = 0.028). After excluding patients with stage Ⅳ colon cancer, the groups showed similar pathologic outcomes and no significant differences in 5-year disease-free survival (73.9% vs 67.4%; P = 0.664) or 5-year overall survival (75.8% vs 67.7%; P = 0.695).

CONCLUSION

A laparoscopic approach for locally advanced colon cancer could be less invasive than an open approach without affecting oncological outcomes in selected patients.

Is it Necessary to Confirm Negative Margins in Gastrectomy for Peritoneal Lavage Cytology-positive Gastric Cancer?

BACKGROUND/AIM

The survival benefit of negative resection margins in patients who undergo gastrectomy with positive peritoneal lavage cytology (CY1) is unknown.

PATIENTS AND METHODS

We reviewed the medical records of 128 patients with CY1 but no other distant metastases who had undergone R1 gastrectomy, 21 of whom had positive margins. We compared overall survival (OS) according to margin status.

RESULTS

The positive-margin group had poorer performance status scores (p=0.02), higher number of patients had undergone limited lymphadenectomy (p=0.01), had type 4 tumors (p=0.01), and undifferentiated type (p=0.02). Median OS was 19.0 and 16.9 months in the groups with negative and positive margins, respectively (HR=1.26, 95%CI=0.75-2.12, p=0.39). An inverse probability of treatment weighted analysis showed an OS of 13.1 and 11.9 months for the groups with negative and positive margins, respectively (HR=0.83, 95%CI=0.43-1.63, p=0.59).

CONCLUSION

The prognoses of patients with CY1 and negative or positive margins may be equivalent.

A phase II trial of dose-reduced nab-paclitaxel for patients with previously treated, advanced or recurrent gastric cancer (OGSG 1302)

BACKGROUND

For unresectable or recurrent advanced gastric adenocarcinoma (AGC), tri-weekly administration of nanoparticle albumin-bound paclitaxel (nab-PTX) at 260 mg/m² achieved a response rate of 27.8% in a phase II trial in Japan. However, frequent neutropenia and peripheral neuropathy limit its use in clinical settings. We, thus, conducted a single-arm phase II trial to investigate the efficacy and safety of a reduced dose (220 mg/m²) of tri-weekly nab-PTX.

METHODS

Eligible patients included those with AGC and ECOG performance status of 0-2 who had received one or more prior chemotherapy containing fluoropyrimidine regimens. A reduced dose of nab-PTX (220 mg/m²) was administered tri-weekly. The primary endpoint was response rate (RR). Secondary endpoints were overall survival (OS), progression-free survival (PFS), disease-control rate (DCR), incidence of adverse events, relative dose intensity (RDI) and proportion of patients receiving subsequent chemotherapy.

RESULTS

Among 33 patients enrolled, 32 were treated with protocol therapy. RR was 3.1% [95% confidence interval (CI), 0-16.2%], which did not reach the protocol-specified threshold (p = 0.966). DCR was 37.5% (95% CI, 21.1-56.3%). Median OS and PFS were 6.3 (95% CI, 4.4-14.2) and 2.2 (95% CI, 1.8-3.1) months, respectively. RDI was 97.8%. Twenty (62.5%) patients received subsequent chemotherapy. Toxicity was relatively mild with the most common grade ≥ 3 adverse events being neutropenia (38%), anemia (13%), fatigue (19%), anorexia (16%), and peripheral neuropathy (13%).

CONCLUSION

Tri-weekly nab-PTX with a reduced dose (220 mg/m²) is not recommended for AGC in a second-line or later setting, despite demonstrating less toxicity than at 260 mg/m². Clinical trial registration The OGSG1302 trial was registered with UMIN-CTR as UMIN000000714.

Biomarker analysis to predict the pathological response to neoadjuvant chemotherapy in locally advanced gastric cancer: An exploratory biomarker study of COMPASS, a randomized phase II trial

Background: The findings of COMPASS, a randomized phase II study, suggested that the regimens and courses of neoadjuvant chemotherapy (NAC) for locally advanced gastric cancer (GC) did not affect the pathological response. However, pathological complete response was achieved in 10% patients who received four courses of either S-1/cisplatin or paclitaxel/cisplatin. We hypothesized that if relevant biomarkers could be used to predict the suitable NAC regimen before treatment initiation, further improvements could be ensured in the outcomes of locally advanced GC.

Materials and Methods: mRNA extraction, real-time polymerase chain reaction, and immunohistochemical analyses were performed using endoscopic biopsy specimens of primary tumors, collected prior to NAC, to determine the clinically relevant biomarkers.

Results: TIMP1, DSG2, RRM1, MUC2, EGFR, ZDHHC14, and CLDN18.2 were identified as biomarker candidates, since their expression was significantly associated with the pathological responses to each NAC regimen. Furthermore, TIMP1 and DSG2 were identified as predictive biomarkers of the pathological response to each NAC regimen.

Conclusions: The effective prediction of the pathological response to NAC regimens in locally advanced GC using biomarkers identified from endoscopic biopsy specimens indicates the possibility of personalizing NAC based on biomarker analysis.

Primary results of a randomized two-by-two factorial phase II trial comparing neoadjuvant chemotherapy with two and four courses of cisplatin/S-1 and docetaxel/cisplatin/S-1 as neoadjuvant chemotherapy for advanced gastric cancer

Aim

Neoadjuvant chemotherapy (NAC) is promising to improve the survival of resectable gastric cancer. However, suitable regimen and treatment duration for NAC have not yet been established.

Methods

We conducted a randomized phase II trial to compare two and four courses of neoadjuvant S-1/cisplatin (SC) and S-1/cisplatin/docetaxel(DCS) using a two-by-two factorial design for locally resectable advanced gastric cancer. Patients with M0 and either T4 or T3 in case of junctional cancer or scirrhous-type cancer received two or four courses of SC or DCS. Then, patients underwent D2 gastrectomy and adjuvant S-1 chemotherapy for 1 year. The primary endpoint was 3-year overall survival. The planned sample size was 120 eligible patients.

Results

Between October 2011 and September 2014, 132 patients were assigned to CS (n = 66; 33 in 2-courses and 33 in 4-courses) and DCS (n = 66; 33 in 2-courses and 33 in 4-courses). The 3-year OS was 58.1% in CS and 60.0% in DCS with hazard ratio of 0.80 (95% CI, 0.48-1.34), while it was 53.1% in the two courses and 65.0% in the four courses with hazard ratio of 0.72 (95% CI, 0.43-1.22). In the survival analysis by duration in each regimen, the 3-year OS was 58.1% for both two and four courses in CS, while it was 48.5% for two courses of DCS and 71.9% for four courses of DCS.

Conclusions

Considering high 3-year OS, four courses DCS has a value to be tested in a future phase III study to confirm superiority of neoadjuvant chemotherapy for locally advanced gastric cancer.

Randomized, Phase II Study of Trastuzumab Beyond Progression in Patients With HER2-Positive Advanced Gastric or Gastroesophageal Junction Cancer: WJOG7112G (T-ACT Study)

PURPOSE

This study evaluated the continuous use of trastuzumab beyond progression (TBP) in human epidermal growth factor receptor 2 (HER2)-positive advanced gastric or gastroesophageal junction (G/GEJ) cancer.

PATIENTS AND METHODS

Patients with HER2-positive advanced G/GEJ cancer refractory to first-line chemotherapy with trastuzumab in combination with fluoropyrimidine and platinum were eligible. Patients were randomly assigned to the paclitaxel (80 mg/m2, days 1, 8, and 15, every 4 weeks) or paclitaxel with trastuzumab (PT; initially 8 mg/kg followed by 6 mg/kg, every 3 weeks) arms. The primary endpoint was progression-free survival (PFS). Secondary endpoints included overall survival (OS), response rate, and safety. Biomarkers such as HER2 expression status in tumor tissue after first-line treatment, HER2 amplification evaluated in serum cell-free DNA, and soluble HER2 levels were analyzed.

RESULTS

Overall, 91 patients were allocated to the paclitaxel (n = 46) and PT (n = 45) arms. The median PFS in the paclitaxel and PT arms was 3.2 and 3.7 months, respectively (hazard ratio [HR], 0.91; 80% CI, 0.67 to 1.22; P = .33), and the median OS in both arms was 10 months (HR, 1.2; 95% CI, 0.75 to 2.0; P = .20). The overall response rates in the paclitaxel and PT arms were 32% and 33%, respectively ( P = 1.00), and safety was comparable between the 2 arms. On exploratory analyses, HER2 positivity of tumor tissues was lost after first-line chemotherapy in 11 (69%) of 16 patients whose tumor tissues were available, and circulating HER2 DNA amplification was detected in 41 (60%) of 68 patients. However, no biomarkers associated with efficacy of TBP were found.

CONCLUSION

The TBP strategy failed to improve PFS in patients with HER2-positive advanced G/GEJ cancer, and no beneficial biomarkers were found.

0453 Longitudinal Relationship Between Insomnia and Work Productivity in Japanese City Government Employees

Introduction

“Presenteeism” refers to the decrease in productivity in employees who are present but not functioning at full capacity due to illness or other medical conditions. It is reported that the cost of presenteeism to businesses is 10 times higher than absenteeism (away from work due to illness or disability). Relative presenteeism is a ratio of actual performance to the performance of most workers at the same job. We analyzed effects of insomnia and depression two years before on presenteeism in a Japanese working population.

Methods

Questionnaire survey was conducted as a part of a cohort study named “Night in Japan Home Sleep Monitoring Study (NinJaSleep Study)” in 2016 and 2018. Participants were the city government employees in a rural city in Shiga prefecture, Japan. Presenteeism, insomnia and depression were analyzed by WHO-HPQ (Health and Work Performance Questionnaire), ISI (insomnia severity index) and PHQ-9 (Patient Depression Questionnaire), respectively. Pearson correlation coefficient analyses were performed to determine the strength of the association between two variables. Logistic regression was performed to estimate the odds ratio (OR) and 95% confidence interval (CI) of poor relative presenteeism (the lowest tertile of the relative presenteeism scores) after 2-year follow up.

Results

1143 subjects (participation rate: 61.7%, 36.7% male, 44.5±11.4 years, BMI: 22.3±3.30) participated in both 2016 and 2018. Participants with poor productivity (poor relative presenteeism) in 2018 was significantly associated with ISI in 2016 (OR: 1.050, 95%CI: 1.010-1.090, p=0.013) but not with PHQ-9 in 2016 (OR: 1.008, 95%CI: 0.972-1.045, p=0.664) after adjusting for age, gender and BMI. Positive correlation was found between the total score of ISI and item 3 of PHQ-9 which asks insomnia or hypersomnia symptom (r=0.6122, P&lt;0.0001).

Conclusion

Insomnia may be an independent risk factor for poor presenteeism. ISI may be useful to predict poor productivity in the future.

Support

Supported in part by a research grant from Investigator-Initiated Studies Program of Merck Sharp & Dohme Corp. / MSD K.K. The opinions expressed in this paper are those of the authors and do not necessarily represent those of Merck Sharp & Dohme Corp. / MSD K.K.”

Differences in disease status between patients with progression after first-line chemotherapy versus early relapse after adjuvant chemotherapy who undergo second-line chemotherapy for gastric cancer: Exploratory analysis of the randomized phase III TRICS trial

BACKGROUND

Second-line chemotherapy (SLC) improves survival in advanced gastric cancer (AGC). Patients receiving SLC are categorized into two disease status groups: tumour progression after first-line chemotherapy and early recurrence after adjuvant chemotherapy. Differences between these groups have not yet been clarified.

PATIENTS AND METHODS

A total of 163 eligible patients registered in the randomized phase III TRICS trial evaluating SLC for patients with AGC was classified into the progressive disease (PD) group (n = 55) or the early relapse (ER) group (n = 108). We compared overall survival (OS), progression-free survival (PFS), overall response rate (ORR), and safety. Adjusted OS and adjusted PFS were estimated using inverse probability of treatment weighting (IPTW).

RESULTS

The ER group had a lower median age than the PD group (66 vs. 72 years; P = 0.016), performance status (PS) 0 was more frequently seen in the ER group (87% vs. 71%; P = 0.012). The adjusted median OS was 13.7 months in the ER group and 13.6 months in the PD group (IPTW hazard ratio [HR]: 1.023; P = 0.854). The adjusted median PFS was 4.9 months in the ER group and 4.4 months in the PD group (IPTW HR: 0.707; P = 0.004). ORR was significantly better in the ER group than the PD group (21.3% vs. 4.9%; P = 0.020). No significant differences were observed in the incidence of adverse events.

CONCLUSIONS

ER was associated with improved PFS and better ORR than PD, although no difference in survival was demonstrated. From the viewpoint of treatment outcome, it seems appropriate to treat patients with ER in the same way as patients with PD.

CLINICAL TRIAL REGISTRATION

UMIN 000002571.

Search for Electron Antineutrino Appearance in a Long-Baseline Muon Antineutrino Beam

Electron antineutrino appearance is measured by the T2K experiment in an accelerator-produced antineutrino beam, using additional neutrino beam operation to constrain parameters of the Pontecorvo-Maki-Nakagawa-Sakata (PMNS) mixing matrix. T2K observes 15 candidate electron antineutrino events with a background expectation of 9.3 events. Including information from the kinematic distribution of observed events, the hypothesis of no electron antineutrino appearance is disfavored with a significance of 2.40σ and no discrepancy between data and PMNS predictions is found. A complementary analysis that introduces an additional free parameter which allows non-PMNS values of electron neutrino and antineutrino appearance also finds no discrepancy between data and PMNS predictions.

[A Case of Advanced Gastric Cancer with Umbilical Metastasis, Pyloric Stenosis, and Peritoneal Dissemination Underwent Palliative Surgery after Chemotherapy]

A 62-year-old woman was diagnosed with gastric cancer, Type 4, cT4b(LN, mesentery of transverse colon), N1 M1H0P1CY1, cStage ⅣB. S-1 and L-OHP(SOX)were administered for 4 courses and clinical response was SD. She interrupted the treatment because of practicing folk therapy. She had an emergency hospitalization due to pyloric stenosis, vomiting, and an umbilical tumor with pain. She was treated with 1 course of mFOLFOX6(5-FU, L-OHP, l-LV)followed by palliative surgery(laparoscopy assisted distal gastrectomy, Roux-en-Y reconstruction, resection of umbilical tumor, and bypass for transverse colon stenosis due to dissemination). The pathological diagnosis was L, Circ, Type 4, 126×89 mm, por> sig, pT4b(SI, mesentery of transverse colon), pN3a(12/13), H0P1CY1, pStageⅣ, and metastatic umbilical tumor. Following surgery, oral administration of mFOLFOX6 is continued. Umbilical metastasis(Sister Mary Joseph's nodule)is associated with poor prognosis, however, appropriate management including symptom control by palliative surgery and continuation of chemotherapy may lead a better prognosis.

Correction to: Automated measurement of bone scan index from a whole-body bone scintigram

The article Automated measurement of bone scan index from a whole-body bone scintigram

A phase II trial of low-dose nab-paclitaxel for patients with previously treated or recurrent advanced gastric cancer (OGSG1302)

350

Background: Paclitaxel is a key drug in second-line chemotherapy for advanced or recurrent gastric cancer (AGC) and nanoparticle albumin-bound paclitaxel (nab-PTX) is also widely used in Japan. A previous phase II trial in Japan showed the effectiveness of nab-PTX (260 mg/m2) administered every 3 weeks (q3w) in patients with AGC with a response rate (RR) of 27.8%; however, toxicity was major concern with grade ≥3 neutropenia (49.1%) and peripheral neuropathy (23.6%). To solve this problem, we investigated the efficacy and safety of low-dose q3w nab-PTX regimen in AGC. Methods: Eligibility requirements included: aged ≥20 years, HER2-negative, histologically confirmed, unresectable or recurrent gastric adenocarcinoma, one or more prior chemotherapy containing fluoropyrimidine regimens, presence of measurable lesion(s) according to RECIST ver. 1.1, ECOG PS of 0–2, and adequate organ function. Nab-PTX was administered at a dose of 220 mg/m2 every 3 weeks. The primary endpoint was the RR. Secondary endpoints were overall survival (OS), progression-free survival (PFS), disease-control rate (DCR), incidence of adverse events, relative dose intensity and proportion of patients who received subsequent chemotherapy. Results: Thirty-three patients were enrolled from 10 institutions in Japan. Of the 32 patients treated with protocol therapy, RR (CR, PR) was 3.1% (95% CI, 0–16.2%), which was not reached the protocol-specified threshold (p = 0.966). DCR (CR, PR, SD) was 37.5% (95% CI, 21.1–56.3%), median OS and PFS were 6.3 months (95% CI, 4.4–14.2) and 2.2 months (95% CI, 1.8-3.1). Relative dose intensity was 97.8% (215 mg/m2). 62.5% of patients received subsequent chemotherapy. Most common grade ≥3 adverse events were neutropenia (38%), anemia (13%), fatigue (19%), anorexia (16%), and peripheral neuropathy (13%). Conclusions: Low-dose regimen of q3w nab-PTX was slightly less toxic, although it did not demonstrate the same effect as the original regimen in response rate. Therefore, it is not recommended for AGC in second or later line setting. Clinical trial information: UMIN 000012701.

Meta-analysis of two randomized phase III trials (TCOG GI-0801 and ECRIN TRICS) of biweekly irinotecan plus cisplatin versus irinotecan alone as second-line treatment for advanced gastric cancer

BACKGROUND

Biweekly irinotecan (CPT-11) plus cisplatin (CDDP) combination (BIRIP) and CPT-11 alone are both expectable options for treating advanced gastric cancer (AGC) in a second-line setting. We conducted a meta-analysis to compare the efficacy and safety of these two regimens in patients enrolled two randomized phase III trials.

PATIENTS AND METHODS

Individual patient-level data from two randomized phase III trials were collected for this study. In both trials, patients with AGC refractory to S-1-based chemotherapy were randomly allocated to BIRIP (CPT-11, 60 mg/m²; CDDP, 30 mg/m², q2w) or to CPT-11 (150 mg/m², q2w).

RESULTS

Cumulative data from 290 eligible patients were evaluated. The OS was 12.3 months [95% confidence interval (CI) 10.5-14.1] in the BIRIP group and 11.3 months (95% CI 10.0-13.2) in the CPT-11 group (hazard ratio 0.87; 95% CI 0.68-1.12, P = 0.272), while PFS was significantly longer in the BIRIP group (4.3 months [95% CI 3.5-5.1]) than in the CPT-11 group (3.3 months [2.9-4.1]; HR 0.77; 95% CI 0.61-0.98, P = 0.035). The response rate was 20.5% in the BIRIP group and 16.0% in the CPT-11 group (P = 0.361). However, the disease control rate was significantly better in the BIRIP group (72.1%) than in the CPT-11 group (59.2%) (P = 0.032). The two groups did not differ significantly in the incidences of grade 3 or worse adverse events.

CONCLUSIONS

Both BIRIP and CPT-11 may be good therapeutic options for patients with AGC as second-line treatment.

CLINICAL TRIAL REGISTRATION

UMIN 000025367.

Health-related quality of life associated with trifluridine/tipiracil in heavily pretreated metastatic gastric cancer: results from TAGS

BACKGROUND

In TAGS, an international, double-blind, phase 3 trial, trifluridine/tipiracil significantly improved overall survival and progression-free survival compared with placebo in heavily pretreated metastatic gastric cancer patients. This paper reports pre-specified quality of life (QoL) outcomes for TAGS.

METHODS

Patients were randomized 2:1 to trifluridine/tipiracil (35 mg/m² twice daily on days 1-5 and 8-12 of each 28-day cycle) plus best supportive care (BSC) or placebo plus BSC. QoL was evaluated at baseline and at each treatment cycle, using the EORTC QLQ-C30 and EORTC QLQ-STO22 questionnaires; results were considered valid for analysis only if ≥ 10% of patients completed the questionnaires. Key QoL outcomes were mean changes from baseline and time to deterioration in QoL. A post hoc analysis assessed the association between QoL and time to deterioration of Eastern Cooperative Oncology Group performance score (ECOG PS) to ≥ 2.

RESULTS

Of 507 randomized patients, 496 had baseline QoL data available. The analysis cut-off was 6 cycles for trifluridine/tipiracil and 3 cycles for placebo. In both treatment groups, there were no clinically significant deteriorations in the mean QLQ-C30 Global Health Status (GHS) score, or in most subscale scores. In a sensitivity analysis including death and disease progression as events, there was a trend towards trifluridine/tipiracil reducing the risk of deterioration of QoL scores compared with placebo. Deterioration in the GHS score was associated with deterioration in ECOG PS.

CONCLUSION

QoL was maintained in TAGS, and there was a trend towards trifluridine/tipiracil reducing the risk of QoL deterioration compared with placebo. Trial registration ClinicalTrials.gov number: NCT02500043.

Automated measurement of bone scan index from a whole-body bone scintigram

Purpose

We propose a deep learning-based image interpretation system for skeleton segmentation and extraction of hot spots of bone metastatic lesion from a whole-body bone scintigram followed by automated measurement of a bone scan index (BSI), which will be clinically useful.

Methods

The proposed system employs butterfly-type networks (BtrflyNets) for skeleton segmentation and extraction of hot spots of bone metastatic lesions, in which a pair of anterior and posterior images are processed simultaneously. BSI is then measured using the segmented bones and extracted hot spots. To further improve the networks, deep supervision (DSV) and residual learning technologies were introduced.

Results

We evaluated the performance of the proposed system using 246 bone scintigrams of prostate cancer in terms of accuracy of skeleton segmentation, hot spot extraction, and BSI measurement, as well as computational cost. In a threefold cross-validation experiment, the best performance was achieved by BtrflyNet with DSV for skeleton segmentation and BtrflyNet with residual blocks. The cross-correlation between the measured and true BSI was 0.9337, and the computational time for a case was 112.0 s.

Conclusion

We proposed a deep learning-based BSI measurement system for a whole-body bone scintigram and proved its effectiveness by threefold cross-validation study using 246 whole-body bone scintigrams. The automatically measured BSI and computational time for a case are deemed clinically acceptable and reliable.

[Palliative Radiotherapy and Sequential Nivolumab Administration for Recurrent Gastric Cancer-A Case Report]

A 52-year-old man underwent total gastrectomy for advanced gastric cancer. The postoperative diagnosis was por1>muc >por2>tub2, pT4a(SE)N3bM0H0P0CY0, pStage ⅢC. He underwent 6 courses of adjuvant chemotherapy with capecitabine plus oxaliplatin. Six months after the surgery, CT showed 2 recurrent lesions: a tumor behind the esophago-jejunal anastomosis and another in the mesentery around the jejuno-jejunal anastomosis. Endoscopy showed intrajejunal invasion. Second-line therapy with paclitaxel and ramucirumab were administered for 3 courses, resulting in rapid progression of the disease. Palliative radiotherapy(39.6 Gy/22 Fr)for both lesions was performed for local control. Sequential administration of nivolumab was started 9 days after terminating radiotherapy. After 6 courses, both tumors markedly reduced PR, and the oral intake of food improved. After 10 courses, there was hyper-progression of the tumor behind the esophago-jejunal anastomosis and shrinkage of the other tumor. Surgery (left upper abdominal exenteration and enucleation of the tumor in the mesentery)was performed to release the jejunal limb obstruction. The tumor behind the esophago-jejunal anastomosis was a poorly differentiated adenocarcinoma, and no viable cancer cells were seen in the tumor in the mesentery. Radiotherapy and immune checkpoint inhibitors may be effective for gastric cancers, although the mechanism of action should be elucidated.

[A Case of Two Curative Resections for the Peritoneal Dissemination of Transverse Colon Cancer]

No large clinical trials have been conducted to prove the efficacy of peritoneal dissemination resection for colorectal cancer, and no evidence has shown the usefulness of resection for metachronous peritoneal dissemination. An elderly woman in her 70s underwent a laparoscopic transverse colectomy for transverse colon cancer in 2014, which was performed by another physician. The pathological diagnosis was tub2-por>muc, pT3, ly2, v0, pN2, and pStage Ⅲb. The patient was followed up with capecitabine plus oxaliplatin(CapeOX)therapy as an adjuvant chemotherapy for 6 months. Three years postoperatively, the CEA level increased to 10 ng/mL, and CT showed a nodular shadow in front of the left prerenal fascia. After the diagnosis of peritoneal dissemination recurrence and 8 courses of capecitabine plus bevacizumab therapy, other metastases were not observed. She was referred to our hospital for surgery and underwent laparoscopic peritoneal dissection at 3 years and 6 months after the first operation. Only one apparent disseminated recurrent lesion, which was resectable, was observed. However, at 4 years and 9 months after the initial operation, CT showed a recurrence of Douglas pouch peritoneal dissemination without any other obvious metastasis. Laparoscopic low anterior resection of the rectum and hysterectomy were performed. Here, we encountered a case that could be radically resected for peritoneal dissemination twice after the colon cancer surgery.

[A Case of Multimodality Treatment Including Carbon Ion Radiotherapy to Multiple Distant Lymph Node Metastasis after a Surgery for Sigmoid Cancer]

We reported a case of a 30s woman who underwent Hartmann's surgery for sigmoid cancer. Her pathological stage was Stage Ⅳ(pT4b, N1b, M1b[liver and lung]). Postoperatively, 10 courses of systemic chemotherapy with FOLFOX plus cetuximab( Cmab)or bevacizumab(Bmab)were administered. After the chemotherapy, partial liver dissection and radiofrequency ablation(RFA)for multiple liver metastasis were performed. After 2 years of systemic chemotherapy with FOLFIRI plus ramucirumab(RAM), no liver or lung metastasis was observed; however, left supraclavicular lymph node and para-aortic lymph node metastases existed and gradually increased. For the purpose of local control, the para-aortic lymph node metastasis was treated with cervical dissection and carbon ion radiotherapy. Therefore, carbon ion radiotherapy was a useful treatment for local control.

[Negative Pressure Wound Therapy for Advanced Recurrent Rectal Cancer]

The incidence of perineal wound complications after extended pelvic surgeries for locally advanced or locally recurrent cancer is high. The management of these refractory complications is usually difficult. Extended pelvic surgeries are commonly associated with severe infectious complications owing to pre-operative chemoradiation therapy, the tissue damage during surgery, and the dead space after radical resections. Negative pressure wound therapy(NPWT)is widely used for the management ofseveral wounds. Recently, the utility ofNPWT has been reported on the management ofinf ectious wound complications post-surgery. Some authors reported the drainage effect of NPWT on pelvic abscess after surgery. However, so far, only a few reports have been published on the usefulness of NPWT in the management of perineal wound disruption or pelvic abscess. We performed NPWT on patients with perineal wound disruption or intractable lymphorrhoea. In these cases, NPWP was effective in early successful treatment. In summary, NPWT is an effective treatment option for perineal disruption and pelvic abscess after surgery for locally advanced or locally recurrent cancers.

Is D2 Lymphadenectomy Essential for Cytology-positive Gastric Cancer? A Retrospective Analysis

BACKGROUND

The appropriate extent of lymphadenectomy on gastric cancer patients with positive peritoneal cytology (CY1) is uncertain. This study retrospectively compared overall survival (OS) after standard and limited lymphadenectomy.

PATIENTS AND METHODS

The medical records from four institutions from 2004 to 2018 were reviewed and data for 91 patients with CY1, but no other distant metastases, who underwent gastrectomy were analyzed. D2 or greater lymphadenectomy and less than D2 lymphadenectomy were performed in 51 and 40 patients, respectively.

RESULTS

Full cohort analyses showed that patients who underwent D2 or greater lymphadenectomy had better prognostic nutritional indices and more such patients received postoperative chemotherapy. The OS in the group treated with D2 or greater lymphadenectomy was also significantly better (p=0.045). Twenty-seven pairs of patients were generated via propensity score matching, and analysis of their OS showed no significant difference between the groups according to lymphadenectomy (p=0.61).

CONCLUSION

The extent of lymphadenectomy may not affect the prognoses for patients with CY1 gastric cancer.

Long-term effects of an oral elemental nutritional supplement on post-gastrectomy body weight loss in gastric cancer patients (KSES002)

Aim

The present study aimed to evaluate the efficacy of short‐term nutritional intervention with an oral elemental diet (ED; Elental; EA Pharma Co., Ltd, Tokyo, Japan) at 300 kcal/day for 6‐8 weeks in the early post‐gastrectomy period on postoperative long‐term body weight loss (BWL).

Methods

We analyzed consecutive patients who were randomly divided to receive the regular diet with or without ED. The control group received regular diet alone post‐gastrectomy, whereas the ED group received 300 kcal ED plus regular diet for 6‐8 weeks. Primary endpoint was percentage (%) BWL (body weight loss; body weight before surgery minus that at postoperative 1 year) by surgical type. Secondary endpoints included changes in nutrition‐related blood parameters.

Results

Of the patients in the original trial, 106 were eligible for efficacy analyses. %BWL at postoperative 1 year was significantly lower in the ED group than in the control group among patients who underwent total gastrectomy (TG) (n = 19 and n = 17, respectively; 9.66 ± 5.98% [95% confidence interval, CI: 6.77‐12.54] vs 15.11 ± 6.78% [95% CI: 11.63‐18.60], P = .015), but not in patients who underwent distal gastrectomy (n = 38 and n = 32, respectively; 5.81 ± 7.91% [95% CI: 3.21‐8.41] vs 5.96 ± 6.20% [95% CI: 3.72‐8.19], P = .933). In multivariate analysis, ED was the only factor affecting %BWL at postoperative 1 year among patients who underwent TG.

Conclusions

Daily nutritional intervention (300 kcal/day ED) for 6‐8 weeks reduced %BWL not only at postoperative 6‐8 weeks but also at 1 year in patients who underwent TG.

Daily nutritional intervention (300 kcal/day elemental diet) for 6‐8 weeks reduced %body weight loss not only at postoperative 6‐8 weeks but also at 1 year in patients who underwent total gastrectomy.

P943The impact of diabetes on patients with frail after endovascular treatments: from I-PAD registry

Background

Diabetes mellitus (DM) is known to be one of the risks of arteriosclerosis. However, it is still unknown whether DM is a risk factor also in secondary prevention of frail patients after endovascular treatments (EVT)

Purpose

To investigate impact of diabetes on patients with frail after EVT.

Methods

From July 2015 to July 2016, 371 consecutive PAD patients who performed EVT were enrolled in I-PAD registry. We could conduct follow up survey 361 patients (446 lesions) and divided into 2 groups; with diabetes (185 patients, 226 lesions) or without diabetes (176 patients, 220 lesions) and analyzed. And among them,we selected 96 patients with frail and divided into 2 groups; with diabetes (49 patients, 70 lesions) or without diabetes (46 patients, 58 lesions) and analyzed. We defined frail patients as the patients with Clinical Frailty Scale 5 (mild frail) or higher. The primary end point was all-cause-death and major adverse limb events (MALE: TLR, TVR, major amputations) at 1 year.

Result

At 1 years in the patients group with diabetes, overall survival and freedom from MALE were significantly lower (81.7% vs 95.8% P<0.0001; 80.0% vs 94.6%, P<0.0001) than the group without diabetes.Among the patients with frail, between the patients group with diabetes and the group without, there is no significant differences in overall survival and freedom from MALE (88.2% vs 88.9% P=0.83; 80.7% vs 84.1%, P=0.55) at 5 years.

Conclusion

The prognosis of patients with diabetes after EVT was worse than the patient without. On the other hand, the prognosis of frail patients with diabetes after EVT was no difference with the frail patient without diabetes in this study.