Impact of neoadjuvant therapy followed by laparoscopic radical gastrectomy with D2 lymph node dissection in Western population: A multi-institutional propensity score-matched study.

Umberto Bracale,Paolo De Martini,Stefano Olmi,Pasquale Dolce,Giovanni Ferrari,Diego Cuccurullo,Felice Pirozzi,Francesco Corcione,Elisa Cassinotti,Antonio Sciuto,Roberto Peltrini,Monica Gualtierotti,Jacopo Andreuccetti,Miloš Bjelović,Dragan Gunjić,Matteo Uccelli,Luigi Boni,Giusto Pignata

doi:10.1002/jso.26657

Abstract

Background and ObjectivesIn the setting of a minimally invasive approach, we aimed to compare short and long‐term postoperative outcomes of patients treated with neoadjuvant therapy (NAT) + surgery or upfront surgery in Western population.MethodsAll consecutive patients from six Italian and one Serbian center with locally advanced gastric cancer who had undergone laparoscopic gastrectomy with D2 lymph node dissection were selected between 2005 and 2019. After propensity score‐matching, postoperative morbidity and oncologic outcomes were investigated.ResultsAfter matching, 97 patients were allocated in each cohort with a mean age of 69.4 and 70.5 years. The two groups showed no difference in operative details except for a higher conversion rate in the NAT group (p = 0.038). The overall postoperative complications rate significantly differed between NAT + surgery (38.1%) and US (21.6%) group (p = 0.019). NAT was found to be related to a higher risk of postoperative morbidity in patients older than 60 years old (p = 0.013) but not in patients younger (p = 0.620). Conversely, no difference in overall survival (p = 0.41) and disease‐free‐survival (p = 0.34) was found between groups.ConclusionsNAT appears to be related to a higher postoperative complication rate and equivalent oncological outcomes when compared with surgery alone. However, poor short‐term outcomes are more evident in patients over 60 years old receiving NAT.

Highlights

Gastric cancer is one of the most common cancers in the world[1,2] and it is the third primary cause of cancer‐related death around the world afflicting more than 400 000 patients each year in China[3] and more than 10 000 cancer‐related deaths in the United States in 2017.4 According to Western guidelines patients with locally advanced gastric cancer (LAGC) should undergo radical gastrectomy with D2 lymph node dissection.[5,6] neoadjuvant therapy (NAT) with a perioperative regimen is recommended for patients with more than or equal to Stage IB resectable gastric cancer.[7]
laparoscopic subtotal gastrectomy (LSG) was performed in 69.1% and 74.2% of cases in the NAT group and the upfront surgery (US) group, respectively (Table 2) whereas laparoscopic total gastrectomy (LTG) was performed in the remaining cases (p = 0.524)
No statistically significant difference was found between the two groups concerning blood loss (p = 0.733), intraoperative complications (p = 0.434), operative time (p = 0.098), nodes harvested (p = 0.190), metastatic nodes (p = 0.400) except for the conversion rate that was higher in the NAT group than in the US group (23.7% vs. 11.3%; p = 0.038)

Summary

Introduction

Gastric cancer is one of the most common cancers in the world[1,2] and it is the third primary cause of cancer‐related death around the world afflicting more than 400 000 patients each year in China[3] and more than 10 000 cancer‐related deaths in the United States in 2017.4 According to Western guidelines patients with locally advanced gastric cancer (LAGC) should undergo radical gastrectomy with D2 lymph node dissection.[5,6] neoadjuvant therapy (NAT) with a perioperative regimen is recommended for patients with more than or equal to Stage IB resectable gastric cancer.[7]. A perioperative regimen for treatment of LAGC was established as a procedural reference model within this setting.[10,11] It appears that NAT can be administered without increasing postoperative morbidity compared with gastrectomy alone, no definitive conclusions can be drawn[12,13] and results from the CRITICS trial show that incomplete preoperative NAT due mainly to toxicity is an independent risk factor in developing postoperative complications.[14] In Eastern Asia, upfront surgery (US) is still recommended as primary treatment and health insurance in Japan and South Korea does not support neoadjuvant treatment for surgically resectable LAGC,[10] despite clinical evidence on the use of NAT are establishing in Japan.[15,16].

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Discussion

Conclusion