Survival benefit of “D2-plus” gastrectomy in gastric cancer patients with duodenal invasion

Background

The optimal extent of lymph node (LN) dissection for gastric cancer with duodenal invasion is yet to be clarified. This study sought to evaluate the significance of gastrectomy with D2-plus lymphadenectomy including posterior LNs along the common hepatic artery (no. 8p), hepatoduodenal ligament LNs along the bile duct (no. 12b) and those behind the portal vein (no. 12p), LNs on the posterior surface of the pancreatic head (no. 13), LNs along the superior mesenteric vein (no. 14v) and para-aortic LNs around the left renal vein (nos. 16a2 and 16b1) dissection.

Methods

Patients with gastric cancer with duodenal invasion undergoing R0 gastrectomy from January 2000 to December 2015 were enrolled. The therapeutic value index (TVI) of each LN dissection was calculated by multiplying the incidence of metastasis to each LN station by the 5-year overall survival (OS) rate of the patients with metastasis to the station.

Results

In total, 117 patients were eligible. The 5-year OS rates (and TVI) of the patients with metastasis to LNs were 40.4% (7.4) in no. 12b, 25.4% (6.8) in no. 13, 32.0% (6.1) in no. 14v, 50.0% (13.0) in no. 16a2 and 40.0% (10.0) in no. 16b1. None of the patients with metastasis in no. 8p or no. 12p survived 5 years or longer.

Conclusion

In a potentially curative gastrectomy for gastric cancer with duodenal invasion, there may be some survival benefit in dissection of nos. 12b, 13, 14v, 16a2 and 16b1 LNs, while no benefit was seen in dissection of nos. 8p or 12p LNs.

     

Prognostic analysis of patients with intra-abdominal infectious complications after laparoscopic-assisted and open radical gastrectomy for gastric cancer – A propensity score-matching analysis

BackgroundTo investigate the incidence and prognosis of intra-abdominal infectious complications (IaICs) after laparoscopic-assisted gastrectomy (LAG) and open radical gastrectomy (OG) for gastric cancer.MethodsThe data of patients who underwent radical gastrectomy (LAG and OG) for gastric cancer at the Fujian Medical University Union Hospital from January 2000 to December 2014 were retrospectively reviewed. A 1:1 propensity score matching (PSM) was used to reduce bias. The incidence and prognosis of postoperative IaICs in the two groups were analyzed.ResultsAfter PSM, no significant difference was found in the baseline data between OG (n = 913) and LAG (n = 913). The incidence of IaICs after OG and LAG was 4.1% and 5.1%, respectively (p = 0.264). The Cox multivariate analysis showed that IaICs were an independent risk factor for overall survival (OS) of patients undergoing gastrectomy (hazard ratio [HR]: 1.65, p < 0.001). Further, LAG was an independent protective factor for OS among the patients with IaICs (HR: 0.54, p = 0.036), while tumor diameter of ≥50 mm (p = 0.01) and pathological TNM stage III (p < 0.001) were independent risk factors. The 5-year OS rate was higher in the patients with IaICs who underwent LAG than in those who underwent OG (51.1% vs. 32.4%, p = 0.042). The prognostic nutritional index was similar in both groups before surgery (p = 0.220) but lower on the first, third, and fifth days after OG than after LAG (p < 0.05).ConclusionsCompared to OG, LAG can improve the prognosis of patients with postoperative IaICs and is therefore recommended for patients at a high risk for IaICs.     

Is tumor size a predictor of preoperative N staging in T2–T4a stage advanced gastric cancer?

BackgroundThe aim of this study was to assess the relationship between tumor size and preoperative N staging in patients with T2–T4a stage advanced gastric cancer.MethodsA total of 697 patients with gastric cancer were analyzed. The correlations between the number of metastatic lymph nodes (LNs) and other clinicopathologic factors were investigated. The Kappa consistency test was used to test the agreement between predicted and pathologic N staging.ResultsMultivariate analysis showed that tumor size was independently (r = 0.987, P < 0.05) and linearly (R² = 0.940, P < 0.05) correlated with the number of metastatic LNs. The numbers of predicted metastatic LNs in patients with primary tumors <2.02 cm, 2.02–4.07 cm, 4.07–6.80 cm, and ≥6.80 cm in size were 0 (Stage N0), 1–2 (Stage N1), 3–6 (Stage N2), and ≥7 (Stage N3), respectively. There was good agreement between N staging predicted by tumor size and pathologic N staging (Kappa value = 0.531, P < 0.05). The overall accuracy of tumor size for preoperative N staging was 82.13%. The 5-year survival rates of patients with predicted Stages N0, N1, N2, and N3 were 80.0%, 71.1%, 56.8%, and 39.8%, respectively (P < 0.05). There were no significant differences in the survival rates of patients with predicted N staging and the corresponding pathologic N staging.ConclusionsTumor size is correlated with the number of LN metastases in patients with stage T2–T4a advanced gastric cancer. The measurements of tumor size can predict preoperative N staging.     

Clinical manifestations in patients with alpha-fetoprotein–producing gastric cancer

Background

Patients with alpha-fetoprotein (afp)–producing gastric cancer have a high incidence of liver metastasis and poor prognosis. There is some controversy about clinical manifestations in these patients.

Methods

Our study enrolled patients who, before surgery, had gastric cancer with serum afp exceeding 20 ng/mL [afp>20 (n = 58)] and with serum afp 20 ng/mL or less [afp≤20 (n = 1236)]. Clinical manifestations were compared between the groups.

Results

Early gastric cancer was more frequent (30.1% vs. 4%) and advanced gastric cancer was less frequent (69.9% vs. 96%) in the afp≤20 group than the afp>20 group (p < 0.001). Liver and lymph node metastasis occurred less frequently in the afp≤20 group (4.4% vs. 27.6%, p < 0.001, and 60.7% vs. 91.4%, p < 0.001, respectively). The 1-, 3-, 5-, and 10-year survival rates of afp≤20 patients were 75.2%, 53.4%, 45.8%, and 34.6% respectively. The 1-, 3-, 5-, and 10-year survival rates of patients with afp greater than 20 ng/mL, but 300 ng/mL or less, were 46.7%, 28.9%, 17.8%, and 13.3% respectively. The 1-, 3-, and 5-year survival rates of patients with serum afp greater than 300 ng/mL were 15.4%, 7.7%, and 0% respectively. The independent predictors for survival time were afp concentration, age, peritoneal seeding, liver metastasis, lymph node metastasis, vascular invasion, TNM stage, curative surgery, serosal invasion, and Lauren classification.

Conclusions

Patients with high serum afp had a high frequency of liver and lymph node metastasis and very poor prognosis. More aggressive management with multimodal therapy (for example, chemotherapy, radiotherapy) might be needed when treating such patients.     

Monitoring the estimated glomerular filtration rate (eGFR) in patients with small-cell lung cancer during chemotherapy: equations based on serum creatinine or cystatin C?

Background

This study compared the differences between the estimated glomerular filtration rate (eGFR) calculated by several equations based on serum creatinine (Scr) and cystatin C (CysC) concentrations for monitoring renal function in patients with small-cell lung cancer (SCLC) during chemotherapy.

Methods

Seventy-one patients with SCLC were retrospectively analyzed. The eGFR before and after each chemotherapy cycle was calculated by the following equations: the chronic kidney disease epidemiology collaboration (CKD-EPI) equation, the modification of diet in renal disease (MDRD) equation, the Cockcroft–Gault (CG) equation, and five CysC-based equations. The patients were compared among the different eGFR groups.

Results

The mean decreases in eGFR_CKD-EPI (?2.25 ± 9.89 ml/min/1.73 m²) between each treatment cycle were more significant than the decreases in eGFR_CG (?0.46 ± 10.17 ml/min/1.73 m²), eGFR_MDRD (?0.48 ± 9.79 ml/min/1.73 m²), and five calculated eGFR_CysC (p < 0.05). Single-/multiparameter analyses showed that patients with a higher body mass index (BMI >23) and receiving more treatment cycles (>3) were at increased risk for developing renal impairment with an eGFR less than 60 ml/min/1.73 m² during chemotherapy.

Conclusions

The eGFR calculated by the CKD-EPI equation changed more significantly between each chemotherapy cycle than did the eGFR from the other equations based on Scr or CysC in patients with SCLC. Oncologists should pay more attention to the renal function of specific patient groups during treatment.

     

The efficacy of albumin–globulin ratio to predict prognosis in cancer patients

International Journal of Clinical Oncology - The goal of this systematic review was to identify all of the research within the last 10&nbsp;years that investigated both the...     

Comparative effectiveness of adjuvant chemoradiotherapy after gastrectomy among older patients with gastric adenocarcinoma: a SEER–Medicare study

Background

Since the INT-0116 trial reported a survival advantage, postoperative chemoradiotherapy (CRT) has been a care standard for US patients in whom gastric adenocarcinoma has been diagnosed. We sought to estimate the association between treatment and survival among the older US Medicare population.

Methods

This is a retrospective cohort study of Medicare beneficiaries aged 65–79 years with stage IB–III gastric adenocarcinoma diagnosed between 2002 and 2009 in a Surveillance, Epidemiology, and End Results region. Patients were categorized on the basis of treatment: (1) gastrectomy only and (2) gastrectomy plus adjuvant CRT. We examined factors associated with receipt of adjuvant CRT, including stage at diagnosis, comorbidity, and tumor subtype. Overall survival was measured from 90 days after gastrectomy until death or the censoring date of December 31, 2010.

Results

Of the 1519 patients who underwent gastrectomy, 41.7% received adjuvant CRT. Factors associated with adjuvant CRT included age younger than 75 years at cancer diagnosis and stage II or stage III cancer. The median overall survival from the time of gastrectomy was 25.1 months (interquartile range 43.7 months) for gastrectomy only and 26.9 months (interquartile range 40.9 months) for adjuvant CRT. Multivariable and propensity-score-stratified models demonstrated a survival benefit associated with adjuvant CRT [hazard ratio (HR) 0.58; 95% confidence interval (CI) 0.50–0.67], although the magnitude was greater for stage II tumors (HR 0.50; 95% CI 0.39–0.61) and stage III tumors (HR 0.58; 95% CI 0.45–0.73) than for stage IB tumors (HR 1.02; 95% CI 0.71–1.45).

Conclusions

Adjuvant CRT, in conjunction with gastrectomy, was associated with a survival benefit among older patients with stage II or stage III tumors.

     

Complications after breast cancer surgery in patients treated with concomitant preoperative chemoradiation: a case–control analysis

Background Nearly 60% of breast cancer cases in Mexico are in advanced stages. At our institution, concomitant preoperative chemoradiation is being used in patients with advanced breast cancer. In the present study, we evaluated the postoperative wound complications and risk factors associated. Patients and methods The study included breast cancer patients from January 2000 to December 2002 treated with concomitant preoperative chemoradiation and mastectomy. Wound complication rates were described along with a nested case–control analysis to evaluate risk factors for postoperative major wound complications. Results We evaluated 360 patients treated with preoperative chemoradiation. About 165 patients (45.8%) developed a wound complication (infection and/or flap necrosis); 60 (16.6%) patients had a surgical site infection (SSI) and 61 (16.9%), flap necrosis; 44 (12.2%) developed both complications, and 25 (6.9%) experienced late dehiscence after suture removal. Epidermolysis, seroma, and hematoma ocurred in 93 (25.8%), 80 (22.2%), and 12 patients (3.3%), respectively. Case–control analysis was conducted in 335 patients. After logistic regression analysis, the sole variable found associated with SSI and/or flap necrosis was epidermolysis (OR = 8.81, 95% CI = 4.52–17.18). Although not significant and of lesser magnitude, adjusted risk estimates of overweight, age >50 years, and type of mastectomy showed the same trend. Conclusions Postoperative wound complications were not different from those observed in non-radiated patients, but its rate was higher. Epidermolysis was associated with SSI and/or flap necrosis. Careful surgical technique should be encouraged.     

Risk factors of “loss of independence” in elderly patients who received gastrectomy for gastric cancer

Gastric Cancer - The aim of this study was to clarify the risk of loss of independence (LOI) following gastrectomy in elderly patients with gastric cancer (GC). In this prospective study, frailty...     

Can the new American Joint Committee on Cancer staging system predict survival in rectal cancer patients treated with curative surgery following preoperative chemoradiotherapy?

BACKGROUND:

Although ypStage has been known as a strong prognosticator of recurrence and survival, the detailed interaction of ypT and ypN classification on a survival rate has never been evaluated.

METHODS:

Between October 2001 and December 2007, in total, 960 patients with locally advanced rectal cancer were enrolled retrospectively at 3 centers. Five‐year overall survival (OS) and disease‐free survival (DFS) rate were calculated for each ypTN classification.

RESULTS:

The ypT classification interacted with ypN classification to affect survival in most categories. Patients with ypStage 0 and I cancers showed a >90% 5‐year OS (ypStage 0, 96.5%; ypStage I, 92.9%; P = .346) and 5‐year DFS (ypStage 0, 90.2%; ypStage I, 90.7%; P = .879). Among ypStage III subgroups, large differences in 5‐year OS (ypStage IIIA, 90.1%; ypStage IIIB, 68.3%; ypStage IIIC, 40.5%; P < .001) and 5‐year DFS (ypStage IIIA, 74.8%; ypStage IIIB, 55.1%; ypStage IIIC, 12.3%; P < .001) were observed. OS and DFS in patients with ypStage IIIA disease were similar to or greater than those in patients with ypStage IIA or IIB/IIC disease. Four patient risk groups were defined: 1) low (ypT0‐isN0, ypT1N0, ypT2N0), 2) intermediate (ypT0‐2N1, ypT3N0), 3) moderately high (ypT0‐2N2, ypT3N1, ypT4N0), and 4) high risk (ypT3N2, ypT4N1‐2). Risk grouping showed a narrower range of survival rate compared with ypStage grouping.

CONCLUSIONS:

ypStage in rectal cancer, defined according to the 7th edition of the American Joint Committee on Cancer staging system, predicts survival for most ypNT classifications. However, patients with ypStage I rectal cancer have a similar prognosis to those with ypStage 0 cancer, and risk grouping reflects more precise survival outcomes than ypStage. Cancer 2012. © 2012 American Cancer Society.     

Analysis of recurrence for locally advanced gastric or gastroesophageal cancer patients after receiving curative gastrectomy ( ＞ D1 ) and its indication for adjuvant chemoradiotherapy

Objective The benefit of adjuvant chemoradiotherapy remains controversial for gastric cancer patients treated with more than D1 dissection. This retrospective analysis is to distinguish the first site of recurrence in patients treated with curative resection and more than D1 dissection and to find any feasible adjuvant concurrent chemoradiotherapy recommendation for them. Methods All patients treated between January 2002 and December 2004 who met the following criteria were analyzed: primary gastric or gastroesophageal cancer, underwent curative gastrectomy ( UICC R0 ) and more than D1 lymphadenectomy,pathologically staged as T3-4N0-1 M0, or any Tx N2-3M0. There were 297 patients analyzed and 19.5%,52. 2%, 17. 8% , 10. 4% of patients had stage Ⅱ ( T3 N0 M0, T1 N2 M0 ), Ⅲa, Ⅲb and Ⅳ ( M0 ) diseases,respectively. 76. 1% of patients received adjuvant chemotherapy, while Only 2 patients underwent adjuvant radiotherapy. Failure patterns and the prognostic factors for locoregional recurrence were analyzed. Results The median follow-up time was 61 months and the follow-up rate was 92. 3%. 145 patients developed recurrence with a median recurrent time of 26 months. Locoregional recurrence was observed in 82 patients and distant metastasis in 79 patients. Gastric stump, anastomosis, intra-abdominal lymph nodes were the most common sites of locoregional recurrence. Liver and lung were the most frequent sites of distant metastasis. Prognostic variables for locoregional recurrence were identified after univariate analysis,including pathologic type ( χ2 = 11.50, P = 0. 009 ), total number of dissected lymph nodes ( χ2 = 6. 65,P =0. 010), the number of positive lymph node ( χ2 =5. 80,P =0. 016), lymph node capsular invasion ( χ2 =pathologic type, total number of dissected lymph nodes, lymph node capsular invation, AJCC TNM stage and Borrmann type were independent prognostic factors for locoregional recurrence ( χ2 = 6. 77,19. 33,17. 84 and 6. 02,P =0. 009,0. 000,0. 000 and 0. 014). Conclusions Locoregional recurrence remains the main cause of failure for locally advanced gastric or gastroesophageal cancer patients even though the patients have had more than D1 lymphadenectomy. The role of adjuvant concurrent hemoradiotheray for those patients is warranted.     

Combined measurement of preoperative α-fetoprotein and des-γ-carboxy prothrombin predicts recurrence after curative resection in patients with hepatitis-B-related hepatocellular carcinoma

Alpha-fetoprotein (AFP) and des-γ-carboxy prothrombin (DCP) are widely used complementary tumor markers for hepatocellular carcinoma (HCC). In this study, we investigated whether preoperative AFP and DCP levels predict recurrence after curative resection in patients with hepatitis B virus (HBV)-related HCC. Records for 267 patients who were diagnosed with HBV-related HCC and who underwent curative resection for HCC were retrospectively reviewed. Patients were divided into two preoperative groups: pre-op I (AFP ≥20 ng/dL and DCP ≥40 mAU/mL) and pre-op II (AFP ≥20 ng/dL and DCP <40 mAU/mL; AFP <20 ng/dL and DCP ≥40 mAU/mL; or AFP <20 ng/dL and DCP <40 mAU/mL). Among 267 patients, 102 (38.2%) patients were classified as pre-op I, whereas the other 165 (61.8%) belonged to pre-op II. During the post-resection follow-up [69.0 (3.0-136.0) months] period, 154 (57.7%) patients developed recurrences [68 (66.7%) patients in pre-op I vs. 86 (52.1%) in pre-op II, p = 0.029]. A multivariate analysis revealed that multiple tumors [hazard ratio (HR), 2.210; 95% confidence interval (CI), 1.185-4.121] and pre-op I (HR: 1.890; 95% CI; 1.080-3.289) were significant predictors for recurrence. Disease-free survival (DFS) was significantly shorter in pre-op I compared to that in pre-op II (20.0 vs. 46.8 months, p = 0.006). Elevated preoperative AFP and DCP levels were associated with a higher recurrence rate and shorter DFS in patients with HBV-related HCC after curative resection. The combined measurement of preoperative AFP and DCP may be a prognostic factor for future recurrence.     

ALDH‐1 expression levels predict response or resistance to preoperative chemoradiation in resectable esophageal cancer patients

Purpose

Operable thoracic esophageal/gastroesophageal junction carcinoma (EC) is often treated with chemoradiation and surgery but tumor responses are unpredictable and heterogeneous. We hypothesized that aldehyde dehydrogenase‐1 (ALDH‐1) could be associated with response.

Methods

The labeling indices (LIs) of ALDH‐1 by immunohistochemistry in untreated tumor specimens were established in EC patients who had chemoradiation and surgery. Univariate logistic regression and 3‐fold cross validation were carried out for the training (67% of patients) and validation (33%) sets. Non‐clinical experiments in EC cells were performed to generate complimentary data.

Results

Of 167 EC patients analyzed, 40 (24%) had a pathologic complete response (pathCR) and 27 (16%) had an extremely resistant (exCRTR) cancer. The median ALDH‐1 LI was 0.2 (range, 0.01–0.85). There was a significant association between pathCR and low ALDH‐1 LI (p ≤ 0.001; odds‐ratio [OR] = 0.432). The 3‐fold cross validation led to a concordance index (C‐index) of 0.798 for the fitted model. There was a significant association between exCRTR and high ALDH‐1 LI (p ≤ 0.001; OR = 3.782). The 3‐fold cross validation led to the C‐index of 0.960 for the fitted model. In several cell lines, higher ALDH‐1 LIs correlated with resistant/aggressive phenotype. Cells with induced chemotherapy resistance upregulated ALDH‐1 and resistance conferring genes (SOX9 and YAP1). Sorted ALDH‐1+ cells were more resistant and had an aggressive phenotype in tumor spheres than ALDH‐1− cells.

Conclusions

Our clinical and non‐clinical data demonstrate that ALDH‐1 LIs are predictive of response to therapy and further research could lead to individualized therapeutic strategies and novel therapeutic targets for EC patients.