Early detection of nonperitoneal recurrence may contribute to survival benefit after curative gastrectomy for gastric cancer

Background

There is no evidence that strict follow-up using cross-sectional imaging after curative gastrectomy benefits survival; however, nonperitoneal recurrence detected early might be treated with additional surgery. The present study examined whether early detection of recurrence by imaging modalities could increase survival, particularly in patients with nonperitoneal recurrence.

Methods

We retrospectively analyzed 218 patients with recurrent gastric cancer after curative gastrectomy performed from 2002 to 2014. The patients were divided into an asymptomatic group (n = 117) and a symptomatic group (n = 101), according to the presence of symptoms at the time of recurrence, to compare clinicopathological characteristics and long-term survival.

Results

Peritoneal recurrence was less frequent in the asymptomatic group (22.2%) than in the symptomatic group (62.4%), the median time to recurrence was shorter (12.7 months vs 18.9 months; P < 0.001), and the median survival time after recurrence was longer (18.7 months vs 7.5 months; P < 0.001). In the asymptomatic group, 10 of 117 patients (8.5%) received additional curative surgery after recurrence. Median overall survival after gastrectomy was not significantly different between the groups (30.1 months for the asymptomatic group vs 30.0 months for the symptomatic group; P = 0.132); however, it was significantly longer among asymptomatic patients with nonperitoneal recurrence compared with symptomatic patients (35.9 months vs 24.0 months; P = 0.039).

Conclusions

The presence of symptoms at recurrence did not affect survival in patients with recurrent gastric cancer. However, detection of nonperitoneal recurrence before the appearance of symptoms may provide survival benefit. Therefore, regular follow-up, including use of imaging modalities, is recommended.

     

Timing of death from tumor recurrence after curative gastrectomy for gastric cancer

In Western literature, there are few studies investigating the predictors of early versus late recurrence after curative gastrectomy for gastric cancer. The current study analyzed (1) patients who died of recurrent gastric cancer and (2) prognostic factors, which can be applied to timing of death from tumor recurrence. Of 492 patients who underwent curative resection (R0) for gastric cancer in the Department of Surgery, Medical Faculty of Istanbul between 1994 and 2000, 142 patients who died of recurrence were included into study. None of the patients had received postoperative adjuvant treatment. The patients were divided into 2 groups: an early recurrence group that included 102 patients who recurred and died within 2 years after surgery, and a late recurrence group, which included 40 patients who died of recurrence more than 2 years after surgery. Clinicopathologic findings were compared between the early and late recurrence groups. Multivariate analysis was performed to investigate the independent factors, which are predictive for early versus late recurrence, and prognostic factors independently associated with the survival period. In multivariate analysis, the early recurrence group, when compared with the late recurrence group, was characterized by lymph node metastasis (N1-3 versus N0; P = 0.002). Overall survival was influenced by nodal status (N1-3 versus N0; P = 0.003), type of operation performed (radical total versus radical subtotal gastrectomy; P = 0.003), Eastern Cooperative Oncology Group performance status (PS 3-4 versus PS 1-2; P = 0.004), and tumor localization (cardia versus corpus and antrum; P = 0.046). In contrast, T stage of the disease was not prognostic for survival, although it was close to statistical significance (P = 0.066). Multivariate analysis showed that poorer performance status at initial presentation (P = 0.001) and lymph node metastasis (P = 0.032) independently correlated with overall survival (P = 0.002). Lymph node status was the most important factor predictive for early versus late recurrence and patients with lymph node metastases were at more risk of death within 2 years after curative operation for gastric cancer. Postoperative chemoradiotherapy should be especially recommended for patients at high risk of recurrence of adenocarcinoma of the stomach or who have undergone curative resection.     

Effect of negative lymph node count on survival for gastric cancer after curative distal gastrectomy

Aims

The aim of this study is to evaluate the long-term effect of negative lymph node (LN) counts on the prognosis after curative distal gastrectomy among gastric cancer patients.

Methods

The study enrolled 634 patients with gastric cancer, who had undergone curative resection (R0) with distal gastrectomy from 1995 to 2004. Long-term surgical outcomes and relationships between the negative LN count and the 5-year survival rate were investigated.

Results

The 5-year survival rate of the entire cohort was 57.6%. The number of metastasis negative LN was positively associated with the retrieved node according to the Pearson’s correlation test (P < 0.001). Cox regression analysis showed the negative LN count was an independent predictor of survival (P < 0.05). Based on the statistical assumption the best fitting linear, linear regression showed a significant survival improvement based on increasing negative LN count for patients with stages I (P = 0.014), II (P = 0.011) and III (P = 0.003). The greatest survival differences were observed at cutoff value 10 negative LN counts for stage I, and 15 for stages II, III and IV.

Conclusion

Negative LN counts can reflect the extent of lymphadenectomy for gastric cancer after curative distal gastrectomy. The higher the negative LN count, the better the survival would be; the best long-term survival outcome was observed on the negative LN count more than 10 (stage I) or 15 (stages II, III, and IV).     

Early postoperative anastomotic hemorrhage after gastrectomy for gastric cancer

Background  

Postoperative anastomotic hemorrhage is a relatively rare complication, but it is lethal if not treated immediately.     

Suture-line recurrence at a jejunojejunal anastomosis after gastrectomy for gastric cancer

Local recurrence at a gastrojejunal anastomosis is common in patients after gastrectomy for gastric carcinoma, but recurrence at a jejunojejunal anastomosis without recurrence at a gastrojejunal anastomosis is extremely rare. We report a case of suture-line recurrence at a jejunojejunal anastomosis without recurrence at the gastrojejunal anastomosis or in the remnant stomach in a patient 23 months after receiving a Billroth II gastrectomy for gastric cancer. We attributed the implantation of cancer cells at the jejunojejunal anastomosis to contamination of the stapler with cancer cells exfoliated in the gastric mucus during the construction of the gastrojejunal anastomosis. We therefore consider that different surgical instruments, such as automatic anastomotic devices and automatic suturing devices, must be used in each phase of the surgical procedure for gastric cancer.     

Postoperative chemoradiotherapy after curative gastrectomy for cancer

I read with interest the paper by Park et al. on postoperativechemoradiotherapy for gastric cancer, published in a recentissue of Annals of Oncology [1] and I fully agree with the     

Local recurrence of gastric adenocarcinomas after gastrectomy

A study of 257 gastric cancer patients treated with gastrectomy and followed to their death showed that (a) the incidence of local recurrence in the field of gastrectomy was 25%; (b) from the three types of gastrectomy used, extended total gastrectomy resulted in the lowest incidence of recurrence, followed by subtotal and total; (c) recurrences were more common in patients with TNM stages I, II, and III tumors where extended total gastrectomy was proven superior (p < 0.05); (d) early stage tumors tended to recur in the gastric remnant and the esophagus; (e) narrow surgical margins and margins involved by disease predisposed to recurrence; (f)not every patient with histologically invaded margins developed recurrence; (g) the risk of recurrence did not decrease with time; (h) the longer the disease-free interval the better the prognosis; (i) the more advanced the original lesion the longer the disease-free interval; (j) of all patients with recurrence only 19% had resectable lesions on reexploration; (k) the longer the disease-free interval the higher the resectability rate; (l) the median interval from recurrence to death was 2 months; (m) the same interval of those undergoing resection was 18 months. Patients with early-stage tumors treated with gastrectomy should be followed closely for local recurrence and should recurrence develop they should be reexplored if there is no evidence of metastasis.     

Suture line recurrence in jejunal pouch replaced after total gastrectomy for gastric cancer

We report a case of suture line recurrence in a jejunal pouch, diagnosed 4 months after total gastrectomy for advanced gastric cancer. The jejunal pouch was made with a linear stapler, without intraluminal irrigation being carried out before anastomosis, and was replaced in an interposition fashion. We propose that the recurrence was caused by the implantation of exfoliated cancer cells in either the intraluminal mucus or on a contaminated stapling device. Received for publication on April 19, 1999; accepted on Sept. 7, 1999     

Quality of life after curative gastrectomy for gastric cancer in a randomised controlled trial

Quality of life (QOL) was studied in gastric cancer patients treated on a randomised, controlled trial comparing D1 (level 1) with D3 (levels 1, 2 and 3) lymphadenectomy. A total of 221 patients were randomly assigned to D1 (n=110) and D3 (n=111) surgery. Quality-of-life assessments included functional outcomes (a 14-item survey about treatment-specific symptoms) and health perception (Spitzer QOL Index) was performed before and after surgery at disease-free status. Patients suffered from irrelative events such as loss of partners was excluded thereafter. Main analyses were done by intention-to-treat. Thus, 214 D1 (106/110=96.4%) and D3 (108/111=97.3%) R0 patients were assessed. Longitudinal analysis showed that functional outcomes decreased at 6 months after surgery and increased over time thereafter, while health perceptions increased over time in general. On the basis of linear mixed model analyses, patients having total gastrectomy, advanced cancer and hemipancreaticosplenectomy, but not complications had poorer QOL than those without. D1 and D3 patients showed no significant difference in QOL. The results suggest that changes of QOL were largely due to scope of gastric resection, disease status and distal pancreaticosplenectomy, rather than the extent of lymph node dissection. This indicates that nodal dissection can be performed for a potentially curable gastric cancer.     

Solitary metastasis to the left axillary lymph node after curative gastrectomy in gastric cancer

Regional lymph node metastasis in advanced gastric cancer is common, whereas axillary lymph node metastasis (ALNM) is rare. We experienced a patient with a solitary ALNM in gastric cancer. A 48-year-old woman underwent curative distal gastrectomy for advanced gastric cancer (P0H0T3N3M0CY0, stage IV). Twenty-one months after the surgery, she complained of an asymptomatic left axillary tumor. Mammography and computed tomography (CT) scans showed the presence of tumors in neither breast nor lung. Fine-needle aspiration of the axillary tumor demonstrated poorly differentiated adenocarcinoma cells, which coincided with the cells of the resected gastric carcinoma. We diagnosed ALNM from gastric cancer and operated on the patient with radical left axillary lymph node dissection. One year after the reoperation, she has had no recurrence. We conclude that gastric cancer can metastasize to unusual sites. A re-radical resection is recommended if curative resection is feasible. Received: March 6, 2002 / Accepted: April 23, 2002 Offprint request to: O. Kobayashi     

Prediction of survival time after curative surgery for advanced gastric cancer.

This study was carried out to define independent prognostic factors influencing survival time and to examine the survival time of patients with advanced gastric cancer treated by curative resection. Six hundred and forty-eight patients were identified of whom 275 patients died of tumor recurrence during follow-up. Univariate analysis using Mantel-Cox analysis, indicated that tumor size, tumor location, gross appearance, degree of gastric wall invasion, lymph node metastasis and operative procedures were significant factors related to survival time (P less than 0.01 to P less than 0.05). Multivariate analysis using the Cox proportional hazard model adjusted for sex, age and other factors, suggested that tumor size (P less than 0.01, relative risk = 1.79), degree of gastric wall invasion (P less than 0.01, rr = 1.24) and lymph node metastasis (P less than 0.01, rr = 2.39) were the most independent prognostic factors statistically, although these three prognostic factors were inter-related. When the tumor is less than 5 cm and there is no serosal invasion or lymph node metastasis, then a longer survival time can be expected (88.7% at 5-years). If the tumor size exceeds 10 cm and there is invasion into neighboring structures and lymph node metastases, then survival time will be short (11.9% at 4-years).     

Total iron-binding capacity is a novel prognostic marker after curative gastrectomy for gastric cancer

Background

Patients with gastric cancer (GC) are affected by changes in iron status. Before surgery, GC patients are likely to have iron-deficiency anemia; and after gastrectomy, patients suffer from low nutritional status and low iron. This study investigated preoperative iron status associated with prognosis after curative gastrectomy for gastric cancer.

Methods

We evaluated preoperative serum hemoglobin (Hgb), Fe and total iron-binding capacity (TIBC) in 298 patients who underwent curative gastrectomy for GC without preoperative chemotherapy, and analyzed these factors’ associations with prognosis after surgery.

Results

Of the 298 patients, 129 (43.2%) had low Hgb levels, and 33 (11.1%) had low TIBC (<?260 µg/dl) that was not associated with Hgb or Fe level. Patients with low TIBC were significantly associated with older age (≥?65 years old; P?=?0.0085), low albumin (<?3.9 g/dl; P?=?0.0388) and high CRP (≥?0.15 mg/dl; P?=?0.0018) in multivariate analysis. Low Fe (<?60 µg/dl) was not associated with disease-free survival (DFS) or overall survival (OS); however, low Fe was associated with longer cancer-specific survival in Stage III GC patients (P?=?0.0333). Both low Hgb and low TIBC were significantly associated with shorter DFS (Hgb: P?=?0.0433; TIBC: P?<?0.0001) and shorter OS (Hgb: P?=?0.0352; TIBC: P?<?0.0001). Low TIBC were significantly associated with shorter DFS (HR 2.167, 95% CI 1.231–3.639, P?=?0.0086) and shorter OS (HR 2.065, 95% CI 1.144–3.570, P?=?0.0173) in multivariate Cox hazard regression analysis.

Conclusions

Preoperative serum TIBC level of GC patients who undergo curative gastrectomy is a novel prognostic marker in univariate and multivariate analyses.

     

Early complications following total gastrectomy for gastric cancer

BACKGROUND: The study shows operative results with complications occurring in first 30 days after total gastrectomy for stomach cancer. METHODS: A retrospective analysis was performed using medical documentation and histological findings for 76 patients after total gastrectomy was done between 1990 and 1997. Mortality and postoperative complications were analyzed. Complications were sorted as specific and nonspecific. All operations were performed either for intestinal gastric cancer located in proximal stomach or for diffuse stomach cancer. All anastomoses were hand sewn. RESULTS: There were 43 male and 33 female patients. Postoperative mortality was 14.4%. The most frequent complications were dehiscence of the oesophago-jejunal anastomosis in 15.8% of operated patients, postoperative temperature without apparent infection in 5.2%, thrombophlebitis in 5.2%, pneumothorax in 3.9%, hepatic necrosis in one patient (1.3%), and perforation of jejunal loop with nasogastric tube in another (1.3%) ended fatally. The average postoperative intra-hospital treatment lasted 12.3 days. Dehiscence of the oesophago-enteric anastomosis, resulted in generalized peritonitis in 66.6%. Six patients succumbed as a consequence, while two survived with subphrenic and interenteric abscesses. Pneumothorax in combination with total gastrectomy was always fatal. CONCLUSIONS: Routine use of stapling surgery, subspecialization in surgery, and better early intensive care monitoring and treatment could reduce the mortality rate.     

Outcome of gastric cancer patients after successful gastrectomy: influence of the type of recurrence and histology on survival

BACKGROUND: The effect of the location of disease recurrence after curative (R0) gastrectomy on patient survival has not been elucidated. The authors hypothesized that the location of recurrence would have a significant influence on survival. METHODS: Medical records of all patients who received treatment for gastric cancer at The University of Texas M. D. Anderson Cancer Center between 1985 and 1998 were reviewed. Patients who underwent R0 resection for gastric cancer and subsequently developed localized (anastomotic) recurrence (LR), lymph node (regional) recurrence (NR), or distant metastases (DM) were analyzed for overall survival (OS). All study factors were entered into a Cox proportional hazards model to provide multivariate hazard ratios. The model was adjusted for the effects of primary site of recurrence, histologic grade, patient age, and location of the primary tumor. RESULTS: This retrospective analysis included 227 consecutive patients. The median survival of patients who developed NR (11 months) was similar to that of patients who developed LR (10 months), but both groups had significantly longer median survival compared with patients who developed DM (7 months; log-rank P = .03). Patients who had well differentiated or moderately differentiated tumors had a longer OS (11 months) than patients who had poorly differentiated tumors (8 months; log-rank P = .02). In this cohort, location of the primary cancer and age at recurrence had no significant impact on OS. CONCLUSIONS: The data from this study suggested that, among patients who undergo R0 gastrectomy for gastric cancer, LR and NR versus DM should be considered a valid stratification factor for randomized trials based on significant differences in survival. Determining whether this stratification should apply to histologic differentiation will require further investigation in a larger multicenter cohort.     

Genetic polymorphism of IGF-I predicts recurrence in patients with gastric cancer who have undergone curative gastrectomy

BackgroundTo our knowledge, no reports have evaluated the effects of genetic polymorphisms of insulin-like growth factor-I (IGF-I) on clinical outcomes of gastric cancer patients.MethodsWe retrospectively analyzed the impact of IGF-I polymorphisms on recurrence-free survival (RFS) in 430 patients with gastric cancer who underwent curative gastrectomy between 2001 and 2005 in our institution.ResultsAmong the 430 gastric cancer patients, 345 were pathological stage I or II, while 85 were stage III or IV. The median 5-year RFS rate was 85.3% (95% confidence interval [CI] 81.4–88.5). In a multivariate Cox model (adjusted for age, gender, histology, pathological stage, adjuvant chemotherapy, and history of diabetes), two IGF-I polymorphisms, rs1520220 and rs2195239, were significantly associated with RFS (hazard ratio [HR] 0.60, 95% CI 0.40–0.91; and HR 0.60, 95% CI 0.41–0.89, respectively, in a per-allele model). When stratified by stage (I–II versus III–IV), rs1520220 in particular was associated with RFS in patients with stage III–IV disease, with a P-value for interaction of 0.01.ConclusionsOur findings indicate that genetic polymorphisms of IGF-I may have a substantial effect on recurrence for gastric cancer patients who have undergone curative gastrectomy. This information may help identify population subgroups that could benefit from IGF-I-targeting agents.     

胃癌根治术后早期复发的临床病理特点及预后分析

目的:探讨胃癌根治术后早期复发的相关因素及预后分析。方法:回顾性分析235例胃癌根治术后复发患者的临床病理资料,对相关参数进行单因素和多因素分析。Kaplan-Meier法进行预后的生存分析。结果:235例患者平均复发时间为术后24.3个月,其中早期复发145例（≤2年）,晚期复发90例（＞2年）。单因素分析显示手术方式、肿瘤大小、脉管侵犯、浸润深度、淋巴结转移、TNM分期、术后化疗与早期复发相关（P<0.05）。多因素分析显示肿瘤大小（P=0.001）、淋巴结转移（P=0.007）、术后化疗（P=0.011）是早期复发的独立影响因素。生存分析显示肿瘤大小（P=0.013）、TNM分期（P<0.01）是预后的独立影响因素。结论:肿瘤大小、淋巴结转移、术后化疗是胃癌早期复发的独立影响因素,且预后与肿瘤大小、TNM分期密切相关。     

胃癌术后早期复发的相关因素分析

目的研究胃癌术后早期复发的相关因素。方法回顾性分析106例胃癌根治术后复发病例的临床资料。结果106例患者平均复发时间为胃癌根治术后18．3个月。其中早期（≤2年）复发者86例（81．1％），晚期（〉2年）复发者20例（18．9％）。单因素分析显示，胃癌术后复发时间与肿瘤大小、浸润深度、区域淋巴结转移、阳性淋巴结数目有关（P〈0．05），而年龄、性别、肿瘤位置、分化程度、首次手术方式、淋巴结清扫范围及术后是否化疗等因素对胃癌复发时间的影响差异无显著性（P〉0．05）。多因素回归分析筛选出浆膜层侵犯与阳性淋巴结个数为胃癌术后早期复发的独立性相关因素（P〈0．05）。结论浆膜层受侵犯及胃周阳性淋巴结数目是预测进展期胃癌根治术后早期复发的最重要因素。