Research progression in clinical treatment of gastric cancer in 2020 / 中华胃肠外科杂志

Gastric cancer is a common type of malignant tumors, but its clinical prognosis remains unsatisfactory. Up to 2020, a growing number of high-quality clinical researches has provided reliable evidence for clinical practice. Evidences from surgery, perioperative treatment and immunotherapy, such as changes in surgical methods, improvement of perioperative chemotherapy and combination of immune and chemotherapy strategy, provided the possibility to improve the clinical efficacy of gastric cancer. In our clinical practice, gastrointestinal surgeons need to integrate the current research progression and develop individualized strategy for different patients, which is expected to further improve the prognosis and quality of life for patients with gastric cancer.

Adjuvant Chemoradiotherapy Vs Neoadjuvant/Perioperative Chemotherapy in Resectable Gastro-esophageal Junction Adenocarcinomas- a Retrospective Analysis

We aimed to conduct the retrospective analysis of resectable Gastro-esophageal junctionadenocarcinomas treated at our facility with either adjuvant chemoradiotherapy (ACT) or neoadjuvant/perioperative chemotherapy (NACT) and investigate their impact on the clinical outcome.A total of79 patients of Gastro -esophageal junction adenocarcinomas completed treatment with curative intentbetween January, 2010 and December 2016 and were included in the analysis. 33 patients receivedadjuvant chemoradiotherapy after curative surgery as per Intergroup 0116 protocol. 46 patientsunderwent curative surgery after 3 cycles of neoadjuvant /perioperative chemotherapy as per UKMAGIC trial regimen. Statistical analysis was done with SPSS version 16 software.The patientsincluded 68 males and 11 females with age ranging from 22-81 years (median 60 years). The followup ranged from 6-71 months (median 14 months). The number of lymph nodes removed at surgerywas 5-25 (median 12). Only 6 patients were node negative in the whole cohort. The number ofpositive lymph nodes ranged from 1-9 in rest of the 73 patients. 12.65% (n=10) patients were diagnosedwith stage IIB, 44.3% (n=35) patients had stage IIIA, 29.1 %( n= 23) patients had stage IIIB and13.9% (n=11) patients had stage IIIC disease. In the adjuvant chemoradiotherapy group, out of 33patients, 7 were dead of disease and 12 were alive with disease at last follow up. In the neoadjuvant/perioperative cohort, out of 46 patients, 13 were dead and 16 were alive with disease. Mediandisease free survival in the adjuvant chemoradiotherapy group was 22 months versus 14 months inthe neoadjuvant/perioperative cohort. The difference was significant on Breslow analysis (GeneralizedWilcoxon, p=.014) and on Tarone Ware (p=.037) but not on Log rank (Mantel-Cox, p=.190) implyingmore of the early events in the NACT group. Hazards ratio for ACT vs. NACT was 0 .703(95% CI0.376-1.317, p=0.272). Hazard ratio for positive nodes was 1.125 ( 95% CI 0.96-1.318,p=0.145).Median DFS for the whole group was18 months(SE 2.912,CI 12.292-23.708) and meanDFS was 23.725 months (SE 2.452, CI 18.919-28.532). Patients receiving adjuvant chemotherapyafter surgery had median overall survival of 39 months versus 26 months in the neoadjuvant arm{p=.039, Wilcoxon Gehan statistic}.In our clinical set-up, adjuvant chemoradiotherapy seems to resultin better overall survival and disease free survival in resectable gastro-esophageal junctionadenocarcinoma though we should be cautious in interpreting retrospective and non-randomizeddata.

Effect of perioperative and postoperative chemotherapy on the prognosis of patients with advanced gastric carcinoma after resection / 中国实用外科杂志

OBJECTIVE: To explore the effect of perioperative and postoperative chemotherapy on the prognosis of patients with advanced gastric cancer after resection. METHODS: From January 2004 to December 2016, a retrospective cohort of 277 stage IV gastric cancer patients after surgical treatment of gastric resection was enrolled in Department of General Surgery,Nanfang Hospital, Southern Medical University. Among them, 228 underwent surgical resection combined with postoperative adjuvant chemotherapy(postoperative chemotherapy group, group A), and preoperative chemotherapy plus surgery resection and postoperative chemotherapy in 49 cases(perioperative chemotherapy group, group B). After generating propensity scores with eight covariates, including gender, age, biological classifications, completion of chemotherapy, depth of tumor infiltration, lymph nodemetastasis, the extent of lymph nodes dissection and type of gastrectomy, 49 patients in group A were one-to-one matched with 49 patients in group B. Kaplan-merier method was used for survival analysis, and Cox proportional risk regression model was used to analyze independent survival risk factors of patients with advanced gastric cancer undergoing surgical resection. RESULTS: Before propensity scores matching(PSM), biological classifications(P<0.001),the completion of chemotherapy(P<0.001), depth of tumor infiltration(P<0.001), lymph node metastasis(P=0.049), the extent of lymphnode dissection(P=0.001) and the type of gastrectomy(P=0.001) significantly differed between two groups. While after PSM, only the completion of chemotherapy were vital different between two groups. After PSM,median survival time of group A and B were 16(95% CI 10.36-21.64) vs 29(95% CI 17.24-40.76) months, which showed not significant difference(P=0.191). The univariate analysis showed that biological classifications, the completion of chemotherapy, lymph node metastasis and the extent of lymphnode dissection were survival prognosis factors. And the multivariate analysis showed that the chemotherapy cycles≤ 2 cycles, lymph node metastasis and the extent of lymphadenectomyless than D2 were independent poor prognostic factors for advanced gastric cancer patients performed with gastrectomy. Notably, the order of chemotherapy and surgery was not independent variate of prognosis(perioperative chemotherapy vs. postoperative chemotherapy: HR 0.986,95%CI 0.539-1.806,P=0.964). CONCLUSION: Perioperative chemotherapy is not the independent variable to improve prognosis of resected advanced gastric cancer patients.Nonetheless, perioperative chemotherapy could benefit patient's chemotherapy tolerance and compliance, which could be attributed to the superiority in survival compared to postoperative chemotherapy. The finding could offer reference and guidance for further design of perspective studies for advanced gastric cancer patients.

Adenocarcinoma gástrico y tumor estromal del estómago sincrónico incidental / Gastric adenocarcinoma and incidental synchronous incidental gastrointestinal stromal tumor

Se presenta el caso de un paciente masculino de 73 años de edad operado por adenocarcinoma del antro gástrico. Se practicó gastrectomía subtotal distal más linfadenectomía D2. Durante el examen anatomopatológico de la pieza quirúrgica se encontró otro tumor pequeño en el espesor de la pared del antro cubierto por mucosa normal, separado del adenocarcinoma. El análisis histológico confirmó otra neoplasia incidental sincrónica, un tumor del estroma gastrointestinal de tipo fusiforme, positivo para el marcador tumoral CD117. El objetivo del trabajo es presentar esta asociación tumoral sincrónica, revisar sus características y las teorías etiopatogénicas actuales de esta condición sincrónica según la literatura especializada(AU)

A case is presented of a 73-year-old male patient who was operated for a gastric adenocarcinoma of the antrum. A distal subtotal gastrectomy plus D2 lymphadenectomy were practiced. During the anatomic and pathologic examination of the surgical piece, a second tiny tumor was found in the wall of the antrum and that was covered with a normal mucosa separated from the adenocarcinoma. The histologic examination confirmed another synchronous incidental neoplasm, a spindle-cell gastrointestinal stromal tumor, positive for the tumor marker CD117. This paper is aimed at presenting synchronous tumor entity, to review its characteristics and the current etiologic and pathogenic theories of this synchronic condition according to the specialized literature(AU)

Can Perioperative Chemotherapy for Advanced Gastric Cancer Be Recommended on the Basis of Current Research? A Critical Analysis

PURPOSE: According to current guidelines, perioperative chemotherapy is an integral part of the treatment strategy for advanced gastric cancer. Randomized controlled studies have been conducted in order to determine whether perioperative chemotherapy leads to improved R0 resection rates, fewer recurrences, and prolonged survival. The aim of our project was to critically appraise three major studies to establish whether perioperative chemotherapy for advanced, potentially resectable gastric cancer can be recommended on the basis of their findings. MATERIALS AND METHODS: We analyzed the validity of the three most important studies (MAGIC, ACCORD, and EORTC) using a standardized questionnaire. Each study was evaluated for the study design, patient selection, randomization, changes in protocol, participating clinics, preoperative staging, chemotherapy, homogeneity of subjects, surgical quality, analysis of the results, and recruitment period. RESULTS: All three studies had serious shortcomings with respect to patient selection, homogeneity of subjects, changes in protocol, surgical quality, and analysis of the results. The protocols of the MAGIC and ACCORD-studies were changed during the study period because of insufficient recruitment, such that carcinomas of the lower esophagus and the stomach were examined collectively. In neither the MAGIC study nor the ACCORD study did patients undergo adequate lymphadenectomy, and only about half of the patients in the chemotherapy group could undergo the treatment specified in the protocol. The EORTC study had insufficient statistical power. CONCLUSIONS: We concluded that none of the three studies was sufficiently robust to justify an unrestrained recommendation for perioperative chemotherapy in cases of advanced gastric cancer.

Preoperative Chemotherapy in Advanced Stomach Cancer (Pros)

In gastric cancer, the only potentially curative treatment is surgery that attempts to achieve curative (R0) resection. However, despite the use of curative resection, a recurrence develops in a high percentage of patients, especially in cases of serosa and/or lymph node involvement. As a strategy to improve the survival of the patients with resectable advanced gastric cancer, neoadjuvant chemotherapy has been evaluated in several phase II trials and a few phase III trials. The results of these trials have confirmed the feasibility and safety of this approach with no apparent increase in surgical complications. Recently, the findings of a large phase III randomized trial (MAGIC trial) have indicated that compared to the use of surgery alone, perioperative chemotherapy, using both a neoadjuvant and adjuvant strategy, decreased the number of T and N stage cancers and improved survival. The results of another recent phase III trial (FNLCC 94012/FFCD 9703) also showed that compared to the use of surgery alone, perioperative chemotherapy improved the R0 resection rate and survival. In both trials, the improved outcomes may be attributed to the use of neoadjuvant chemotherapy because of poor compliance with adjuvant chemotherapy. These results cannot be directly translated to clinical practice in Korea due to differences in surgical techniques and outcomes. However, the findings of a few small phase II and III trials performed in patients with locally advanced gastric cancer in Korea have also suggested that neoadjuvant chemotherapy would result in the improvement of the R0 resection rate and down-staging of the disease. More effective chemotherapy regimens are needed in future large randomized trials to determine the subset of patients that will benefit from neoadjuvant chemotherapy and to determine the extent of benefit.

Huge Choroid Plexus Carcinoma in an Infant

Choroid plexus carcinoma is a rare malignant brain tumor that occurs predominantly in childhood. A 203-day-old infant was admitted to our hospital with macrocephaly and right hemiparesis. The skull protruded diffusely in the left parietal area. Brain magnetic resonance imaging) revealed a huge mass in the left ventricle. We performed an open biopsy and discovered a choroid plexus carcinoma. The tumor bled very easily and hemostasis was difficult. After three cycles of chemotherapy, we resected the entire mass in a staged operation. Chemotherapy enabled us to resect the entire tumor by reducing its size. We report this case to stress the benefits of preoperative chemo-therapy and review the relevant literature.