Is adjuvant chemotherapy necessary for early gastric cancer?

Objective:To quantify the potential benefit of adjuvant chemotherapy (ACT) with respect to survival, and to identify factors for predicting prognoses in early gastric cancer patients.Methods:Patients with pT1 gastric cancer (GC) who underwent radical resection with D2 lymphadenectomy were retrospectively analyzed. Based on lymph node metastasis (LNM) status and treatment regimens, patients were classified into groups, and clinicopathological variables, overall survival (OS), and disease-specific survival (DSS) were compared.Results:Of 1,050 enrolled patients, 151 patients (14.4%) had a positive LNM status. Submucosal invasion, undifferentiated state, tumor size > 2 cm, ulceration, and lymphovascular invasion were independent risk factors for LNM using multivariate analyses. The 5-year OS of all patients was 96.4%. HER2 positive, perineural invasion, and LNM were independent factors for worse survival. Patients with pT1N3 GC had a worse 5-year OS and DSS than pT1N0, pT1N1, and pT1N2 patients (P < 0.001). The 5-year OS and DSS for pT1N1 patients showed no significant difference between ACT and surgery only patients. For pT1N2 patients, the 5-year OS and DSS showed no significant difference between S-1 and Xelox treatments. For pT1N3 patients, 7 (36.8%) received S-1, while 12 (63.2%) received Xelox treatment. Patients receiving Xelox treatment showed a better 5-year OS (75.0% vs. 14.3%) and DSS (81.8% vs. 20.0%) than patients receiving S-1 (P < 0.05).Conclusions:Curative surgery only was adequate for patients with pT1N0 and pT1N1. Xelox showed no survival benefits for pT1N2 patients. Therefore, S-1 is the optimal choice for pT1N2 patients, when considering adverse effects. Xelox is recommended for pT1N3 patients.     

Is there a role for nontraditional resection of early gastric cancer?

Current trends in the treatment of gastric cancer indicate the emergence of a more sophisticated approach, with tailored therapy applied to individual cases. Treatment includes a broader spectrum of therapeutic options (Fig. 3), including EMR, laparoscopic or laparoscopy-assisted surgery, modified radical surgery, and typical radical surgery with lymph node dissections. Precise characterization of the lesions, especially the depth of invasion in the gastric wall, its size, histology and whether there is ulceration, is the key to successful treatment of N0 mucosal cancer. Micrometastasis and metastasis at the molecular level are issues that require further investigation. Laparoscopic surgery may be more widely accepted. The limitations of nodal dissection based on the concept of a sentinel node should be carefully evaluated in future studies. [figure: see text] Many treatment options, ranging from minimally invasive surgery to D2 node dissection, are available to the surgical oncologist who is treating EGC. As more information is gathered, surgeons will be better able to select patients who are good candidates for minimal surgical procedures.     

Emergency surgery for perforated gastric malignancy: An institution’s experience and review of the literature

Objectives

The aim was to evaluate the outcome of patients who underwent surgery for perforated gastric malignancies.

Methods

A review of all patients who underwent surgery for perforated gastric malignancy was performed.

Results

Twelve patients (nine gastric adenocarcinoma and three B-cell lymphoma) formed the study group. Ten (83.3%) had subtotal gastrectomy performed, while two (16.7%) underwent total gastrectomy. All eight patients with adenocarcinoma who survived the initial operation fared poorly. The two patients with lymphoma who survived the surgery underwent subsequent chemotherapy has no disease recurrence currently.

Conclusion

Surgery in perforated gastric malignancy is fraught with numerous challenges.     

“Burned out” testicular seminoma presenting as a primary gastric malignancy

In contrast to primary gastric adenocarcinomas, germ cell tumors are potentially curable even when metastatic. It is therefore essential for clinicians and pathologists to be aware of the spectrum of unusual manifestations of germ cell malignancies. Here we report on a 55-year-old man who presented with clinical and endoscopic features indicative of a primary gastric carcinoma. Surprisingly, the ulcerative mucosal lesion was found to be due to a metastasis from an occult, “burned-out” testicular seminoma. This case describes the radiological and pathological features that helped differentiate this rare situation from the much more common gastric adenocarcinoma, and extends the diagnostic possibilities that must be considered in patients presenting with gastric ulcers.     

Laparoscopic assisted distal gastrectomy for early gastric cancer: Is it an alternative to the open approach?

ObjectiveThis study aims to compare short term outcomes and oncological value of laparoscopy assisted (LADG) and open distal gastrectomy (ODG) in the treatment of early gastric cancer.MethodsMeta-analysis of 12 studies, including three randomized controlled trials, published between 2000 and 2007, comparing laparoscopy assisted and open distal gastrectomy in 951 patients with early gastric cancer, was done. Outcomes of interest were operative data, lymph node clearance, postoperative recovery complications.ResultsOverall morbidity rate was significantly less with LADG (10.5% versus 20.1%, P = 0.003, OR 0.52, CI 0.34–0.8). A mean of 4.61 less number of lymph nodes dissected than ODG (CI ?5.96, ?3.26 P < 0.001) when all studies are included. There was no difference between the two groups in number of lymph nodes dissected when less than D2 lymphadenectomy was done (2.44 nodes less in LADG group, CI ?5.52, 0.63; P = 0.12). LADG patients had less operative blood loss (mean of 151 ml, P < 0.001), less time to walking, oral intake and flatus. LADG patients had less length of hospital stay (5.7 days, P < 0.001), postoperative fever and pain. ODG group showed significantly less operative time. There was no significant difference between the two groups in the incidence of anastomotic complications and wound infection.ConclusionLADG is a safe technical alternative to ODG for early gastric cancer with a lower overall complication rate and enhanced postoperative recovery. Endorsing LADG as a better alternative to ODG requires data on long term survival, quality of life and cost effectiveness.     

The safety and efficacy of Cyberknife® for thymic malignancy

PurposeTo evaluate the safety and efficacy of Cyberknife® (CK) for the treatment of primary or recurring thymic tumours.Materials and methodsWe retrospectively reviewed 12 patients (16 tumour lesions) with primary or recurring thymic tumours who were treated with CK between March 2008 and October 2017. Their data was stored in prospectively collected database. Kaplan–Meier method was used to calculate survival curves.ResultsFive patients (41.7%), who had inoperable disease or refused surgery, were treated with CK initially, and 7 patients (58.3%) were treated with CK when they had recurrence diseases. The disease sites treated with CK were primary tumour site (5), regional lymph nodes (4), tumour bed (3), chest wall (2), pleura (1), and bone (1). The median target volume was 43.8 cm³ (range, 13.1–302.5 cm³) for the 16 tumour lesions. The median follow-up time was 69.3 months (range, 9.7–124.8 months). The median survival time was 48.2 months, and the 5-year and 10-year OS rates were 68.2% and 45.5%, respectively. A high response rate for the tumour lesions irradiated with CK was obtained. Only one patient (8%) experienced in-field recurrence, and the 5-year local recurrence free survival was 90.9%. A case indicated that CK may induce the abscopal effect, which provides the potential to combine CK and immunotherapy. No severe radiation related toxicities were observed, and no treatment related death occurred.ConclusionCK treatment resulted in good outcomes, particularly local control, with minimal side effects, in highly selected patients with primary and recurring thymic tumours. More studies with larger sample are needed.     

Expression of stromal cell-derived factor-1α is an independent risk factor for lymph node metastasis in early gastric cancer

Lymph node metastasis is considered to be a significant prognostic factor for early gastric cancer (EGC). However, no real consensus exists on which patient and/or tumor characteristics are associated with lymph node metastasis. We investigated whether stromal cell-derived factor (SDF)-1α expression correlates with lymph node metastasis in patients with EGC by immunohistochemically examining the expression of SDF-1α in 138 archival tissue specimens of EGC. Of these specimens, 59 (42.8%) and 79 (57.2%) were grouped into SDF-1α-positive and SDF-1α-negative groups, respectively. No significant differences existed with respect to age, gender, tumor location, proportion of tumors >20 mm in size, macroscopic type, depth of invasion or histology between the SDF-1α-positive and -negative groups. However, the SDF-1α-positive group was significantly correlated with lymphovascular invasion and lymph node metastasis. Results of the univariate analyses indicated that lymphovascular invasion, undifferentiated histology and SDF-1α positivity were statistically significant risk factors affecting lymph node metastasis in patients with EGC. Multivariate analyses showed that lymphovascular invasion [hazard ratio (HR), 8.595; 95% confidence interval (CI), 1.694-43.595; P=0.009], undifferentiated histology (HR, 2.965; 95% CI, 1.037-8.471; P=0.043) and SDF-1α positivity (HR, 2.108; 95% CI, 1.316-10.135; P=0.013) were independent risk factors predicting lymph node metastasis in EGC. In conclusion, these results suggest that SDF-1α expression in tumor cells is a predictive marker of lymph node metastasis in EGC.     

Is the eCura system useful for selecting patients who require radical surgery after noncurative endoscopic submucosal dissection for early gastric cancer? A comparative study

Background

We have established a risk-scoring system, termed the “eCura system,” for the risk stratification of lymph node metastasis in patients who have received noncurative endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). We aimed to clarify whether this system contributes to the selection of patients requiring radical surgery after ESD.

Methods

Between 2000 and 2011, 1,969 patients with noncurative ESD for EGC were included in this multicenter study. Depending on the treatment strategy after ESD, we had patients with no additional treatment (n = 905) and those with radical surgery after ESD (n = 1,064). After the application of the eCura system to these patients, cancer recurrence and cancer-specific mortality in each risk category of the system were compared between the two patient groups.

Results

Multivariate Cox analysis revealed that in the high-risk category, cancer recurrence was significantly higher (hazard ratio = 3.13, p = 0.024) and cancer-specific mortality tended to be higher (hazard ratio = 2.66, p = 0.063) in patients with no additional treatment than in those with radical surgery after ESD, whereas no significant differences were observed in the intermediate-risk and low-risk categories. In addition, cancer-specific survival in the low-risk category was high in both patient groups (99.6 and 99.7%). A limitation of this study is that it included a small number of cases with undifferentiated-type EGC (292 cases).

Conclusions

The eCura system is a useful aid for selecting the appropriate treatment strategy after noncurative ESD for EGC. However, caution is needed when applying this system to patients with undifferentiated-type EGC.

     

Short- and long-term outcomes of endoscopic submucosal dissection for early gastric cancer in elderly patients aged 75 years and older

Background

Only a few studies have reported long-term outcomes for endoscopic submucosal dissection (ESD) of early gastric cancer (EGC) in elderly patients. The aim of this study was to evaluate the efficacy of ESD for EGC in elderly patients ≥75 years with respect to both short- and long-term outcomes.

Methods

We reviewed the clinical data of elderly patients ≥75 years who had undergone ESD for EGC at Tonan Hospital from January 2003 to May 2010.

Results

A total of 177 consecutive patients, including 145 with curative resection (CR) and 32 with noncurative resection (non-CR), were examined. Of the 32 patients with non-CR, 15 underwent additional surgery, and lymph node metastases were found in 3 patients. The remaining 17 patients were followed without additional surgery because of advanced age or poor general condition. Procedure-related complications, such as post-ESD bleeding, perforation and pneumonia, were within the acceptable range. The 5-year survival rates of patients with CR, those with additional surgery after non-CR, and those without additional surgery after non-CR were 84.6, 73.3, and 58.8 %, respectively. No deaths were attributable to the original gastric cancer; patients succumbed to other illnesses, including malignancy and respiratory disease.

Conclusions

In elderly patients, ESD is an acceptable treatment for EGC in terms of both short- and long-term outcomes. Careful clinical assessment of elderly patients is necessary before ESD. After ESD, medical follow-up is important so that other malignancies and diseases that affect the elderly are not overlooked.

     

Research progress of minimally invasive surgery for gastric cancer

Since the first laparoscopic radical surgery for early gastric cancer 30 years ago, there has been a gradual shift from“open” to “minimally invasive” surgery for gastric cancer. This transition is due to advancements in refined anatomy, enlarged field of view, faster recovery, and comparable oncological outcomes. Several high-quality clinical studies have demonstrated the safety and effectiveness of laparoscopy in the treatment of both early and locally advanced gastric cancer. The role of perio...     

Intraperitoneal chemotherapy for gastric cancer: A contemporary perspective

<正>Stage Ⅳ gastric cancer and peritoneal metastasis Gastric cancer is one of the most common malignancies worldwide and is a leading cause of cancer-related deaths(1). Over the past few decades, advances in surgical techniques and chemotherapy have improved the prognosis for patients with gastric cancer. Despite these advances,     

Is preoperative staging enough to guide lymph node dissection in clinically early gastric cancer?

Gastric Cancer - Limited by the accuracy of preoperative staging, some cases of gastric cancer invading the muscularis propria (pT2) are underestimated as early gastric cancer (EGC) in the...     

Stopping a trial early in oncology: for patients or for industry?

We read the article by Trotta et al. [1] with interest and agreethat reporting of randomized controlled trials (RCTs) beforemeeting protocol-defined criteria for conducting a final analysisis an important and complex issue. However, we differ from someof their conclusions. The authors analyzed 25 RCTs that were reported from 1997 to2007 that were selected for review based on     

Epstein–Barr virus positivity,not mismatch repair-deficiency,is a favorable risk factor for lymph node metastasis in submucosa-invasive early gastric cancer

Background

Epstein–Barr virus (EBV)-associated gastric cancer (GC) and microsatellite-instability-high GC are associated with a low prevalence of regional lymph node metastasis (LNM). To evaluate the feasibility of endoscopic treatment of EBV-associated and/or microsatellite-instability-high early GC (EGC), we analyzed the risk factors for LNM using a large series (n = 756) of submucosa-invasive (SM) EGC.

Methods

EBV-encoded RNA in situ hybridization (EBER ISH) and immunohistochemistry for four mismatch repair (MMR) proteins (MLH1, PMS2, MSH2, and MSH6) were performed. The clinicopathologic features and results of EBER ISH and immunohistochemistry were compared according to the LNM status.

Results

Among the cases, 146 EGCs (19.3 %) showed LNM. EBV negativity, larger tumor size (greater than 2 cm), deeper level of submucosal invasion, submucosal invasion depth greater than 500 µm, presence of ulceration, and presence of lymphovascular invasion (LVI) were associated with LNM. However, the MMR deficiency was not correlated with LNM. On multivariate regression analysis, larger tumor size (greater than 2 cm; odds ratio 1.6, p = 0.030), deeper level of submucosal invasion (odds ratio 2.9, p = 0.001), LVI (odds ratio 7.4, p < 0.001), and EBV negativity (p = 0.020) were independent risk factors for LNM in SM EGCs.

Conclusions

EBV positivity was a favorable risk factor for LNM in SM EGC. However, MMR deficiency was not associated with the status of LNM. Thus, we suggest that examination with EBER ISH could be considered for endoscopic resected specimens, especially in cases of SM EGC showing no LVI and clear resection margins.