Curative Gastrectomy Research Articles

Preoperative Neutrophil-to-Lymphocyte Ratio may Predict Postoperative Pneumonia in Stage I-III Gastric Cancer Patients After Curative Gastrectomy: A Retrospective Study.

Several studies have demonstrated that diverse systemic inflammatory-based prognostic parameters predict a poor prognosis in patients with gastric cancer. However, few studies have focused on the relationships between postoperative complications and systemic inflammatory-based prognostic parameters after curative gastrectomy. We investigated the relationships between postoperative complications and these parameters and assessed the clinical utility of the parameters as predictors of postoperative complications in patients with stage I-III gastric cancer. We retrospectively reviewed 300 patients who underwent curative gastrectomy for stage I-III gastric cancer. All postoperative complications were classified as infectious or noninfectious. We evaluated the relationships between postoperative complications and clinical factors, including systemic inflammatory-based prognostic parameters. In total, 101 patients (33.7%) had postoperative Clavien-Dindo grade II-IV complications, and 54 (18.0%) patients developed infectious complications including pancreatic fistula, pneumonia, anastomotic leak, intra-abdominal abscess, and cholecystitis. The relationships between postoperative complications and systemic inflammatory-based prognostic parameters were evaluated by the areas under the receiver operating characteristic curves. Postoperative pneumonia was identified as the most sensitive complication to the systemic inflammatory-based prognostic parameters. Multivariate analysis revealed that preoperative neutrophil-to-lymphocyte ratio (odds ratio, 14.621; 95% confidence interval, 1.160-184.348; p = 0.038) was an independent predictor of pneumonia. Preoperative neutrophil-to-lymphocyte ratio may be a useful predictor of postoperative pneumonia in patients with stage I-III gastric cancer after curative gastrectomy.

Textbook outcome and survival of robotic versus laparoscopic total gastrectomy for gastric cancer: a propensity score matched cohort study

Textbook outcome is a composite quality measurement of short-term outcomes for evaluating complex surgical procedures. We compared textbook outcome and survival of robotic total gastrectomy (RTG) with those of laparoscopic total gastrectomy (LTG). We retrospectively reviewed 395 patients (RTG, n = 74; LTG, n = 321) who underwent curative total gastrectomy for gastric cancer via minimally invasive approaches from 2009 to 2018. We performed propensity score matched analysis to adjust for potential selection bias. Textbook outcome included a negative resection margin, no intraoperative complication, retrieved lymph nodes > 15, no severe complication, no reintervention, no unplanned intensive care unit admission, hospitalization ≤ 21 days, no readmission after discharge, and no postoperative mortality. Survival outcomes included 3-year overall and relapse-free survival rates. After matching, 74 patients in each group were selected. Textbook outcome was similar in the RTG and LTG groups (70.3% and 75.7%, respectively), although RTG required a longer operative time. The quality metric least often achieved was the presence of severe complications in both groups (77.0% in both groups). There were no differences in the 3-year overall survival rate (98.6% and 89.7%, respectively; log-rank P = 0.144) and relapse-free survival rate between the RTG and LTG groups (97.3% and 87.0%, respectively; log-rank P = 0.167). Textbook outcome and survival outcome of RTG were similar to those of LTG for gastric cancer.

Prediction of long-term survival after gastrectomy using random survival forests.

No well validated and contemporaneous tools for personalized prognostication of gastric adenocarcinoma exist. This study aimed to derive and validate a prognostic model for overall survival after surgery for gastric adenocarcinoma using a large national dataset. National audit data from England and Wales were used to identify patients who underwent a potentially curative gastrectomy for adenocarcinoma of the stomach. A total of 2931 patients were included and 29 clinical and pathological variables were considered for their impact on survival. A non-linear random survival forest methodology was then trained and validated internally using bootstrapping with calibration and discrimination (time-dependent area under the receiver operator curve (tAUC)) assessed. The median survival of the cohort was 69 months, with a 5-year survival of 53.2 per cent. Ten variables were found to influence survival significantly and were included in the final model, with the most important being lymph node positivity, pT stage and achieving an R0 resection. Patient characteristics including ASA grade and age were also influential. On validation the model achieved excellent performance with a 5-year tAUC of 0.80 (95 per cent c.i. 0.78 to 0.82) and good agreement between observed and predicted survival probabilities. A wide spread of predictions for 3-year (14.8-98.3 (i.q.r. 43.2-84.4) per cent) and 5-year (9.4-96.1 (i.q.r. 31.7-73.8) per cent) survival were seen. A prognostic model for survival after a potentially curative resection for gastric adenocarcinoma was derived and exhibited excellent discrimination and calibration of predictions.

The Combination of Preoperative Skeletal Muscle Quantity and Quality is an Important Indicator of Survival in Elderly Patients Undergoing Curative Gastrectomy for Gastric Cancer.

The diagnosis of sarcopenia emphasizes both, the quantity and quality of skeletal muscle. However, the impact of the combination of muscle quantity and quality on long-term survival remains unclear. This study aimed to assess the impact of the combination of skeletal muscle quantity and quality on long-term outcomes in patients with gastric cancer who underwent curative resection. We retrospectively assessed 242 patients aged ≥ 65ears who underwent curative gastrectomy between 2006 and 2015. The psoas muscle mass index (PMI) and intramuscular adipose tissue content (IMAC) were measured on preoperative computed tomography as skeletal muscle quantity and quality, respectively. The sarcopenia stage was classified by the combination of preoperative skeletal muscle quantity and quality (non-sarcopenia, sarcopenia, and severe sarcopenia). Prognostic factors for the 5-year overall survival (OS), non-cancer-specific survival (non-CSS), and cancer-specific survival (CSS) were evaluated by multivariable Cox regression. The median follow-up period was 63.2months. The non-sarcopenia, sarcopenia, and severe sarcopenia groups comprised 88, 121, and 33 patients (36.4%, 50.0%, and 13.6%), respectively. The severe sarcopenia group was older, and had a greater depth of invasion, than the non-sarcopenia group. Multivariable analysis revealed severe sarcopenia as an independent predictive indicator of OS (hazard ratio [HR] 4.01; 95% confidence interval [CI] 1.75 to 9.22) and non-CSS (HR 3.27; 95% CI 1.61 to 6.67), but not CSS. The combination of preoperative skeletal muscle quantity and quality was useful for predicting survival, especially death from other diseases, in elderly patients who underwent gastrectomy for gastric cancer.

P-77 Risk factors and clinical outcomes of post-gastrectomy sarcopenia newly developed after curative resection for gastric cancer

Sarcopenia is characterized by progressive and generalized loss of skeletal muscle mass and strength. GC is among the most common causes of sarcopenia. Sarcopenia is an independent predictor of postsurgical outcomes, including various postoperative complications, and shortened overall survival (OS) in many gastrointestinal cancers, including GC. This may arise because patients with sarcopenia generally have a poor nutritional status. Therefore, nutritional status should be an important prognostic factor in patients with GC postoperatively. Sarcopenia predicted the 1-year mortality in elderly patients undergoing GC surgery. Thus, knowing whether newly developed sarcopenia after surgical resection increases the risk of poor outcomes is meaningful for clinical practice because it may provide new nutritional intervention ideas to achieve better prognosis among patients with GC. However, there is a lack of research on newly developed sarcopenia postoperatively. Therefore, this study aimed to investigate the risk factors and clinical impact of post-gastrectomy sarcopenia newly developed after surgical resection on the prognosis of patients undergoing curative gastrectomy for GC. The clinicopathological data of 573 consecutive patients with GC who underwent curative gastrectomy were reviewed. Skeletal muscle mass and abdominal fat volume were measured using abdominal CT. Forty-six (8.0%) patients were diagnosed with preoperative sarcopenia. Among the 527 patients without sarcopenia, 57 (10.8%) were diagnosed with post-gastrectomy sarcopenia newly developed 1 year after curative gastrectomy. Female sex, weight loss, proximal location of the tumor, and differentiated tumor were significant risk factors of post-gastectomy sarcopenia newly developed after curative gastrectomy. There was a significant difference in the 5-year overall survival among the preoperative sarcopenic, non-sarcopenic, and post-gastrectomy sarcopenic groups (P = .017). Especially, there was a significant difference between non-sarcopenic and post-gastrectomy sarcopenic groups (P = .009). However, there was no significant difference in the 5-year disease-free survival among the groups (P = .49). Since newly developed sarcopenia after surgical resection had an influence on overall survival, patients with high sarcopenia risks after curative gastrectomy may require early nutritional support.

P-83 The efficacy of chemotherapy for gastric cancer with early recurrence during or after adjuvant S-1

Adjuvant chemotherapy with S-1 monotherapy after curative gastrectomy is one of the standard treatments in Japan for patients with gastric cancer (GC). Reportedly, early recurrence during or within 6 months after adjuvant chemotherapy has a poor prognosis. The aim of this study was to investigate the efficacy of chemotherapy for GC with early recurrence during or after adjuvant chemotherapy of S-1.

P-241 Metastatic lymph node ratio as an addition to the nodal evaluation of TNM staging: A new sight for prevention of stage migrations

TNM staging is a routine grading system for gastric cancer, but the survival of gastric cancer gets better with early diagnoses and a better management with the correlation of oncology and general surgery departments. Making additions to TNM classification is important in terms of clarifying surveillance and preventing stage migrations. The purpose of this study was to evaluate the metastatic lymph node ratios in locally advanced gastric cancer patients who have undergone curative gastrectomy with D2 dissection. From January 2011 to December 2015, 341 patients were diagnosed with gastric adenocarcinoma and 226 patients underwent curative gastrectomy in our hospital. As curative gastrectomies with R0 resection and patients without distant metastasis were included in the study, palliative surgeries, R1-R2 resections, emergent surgeries and surgeries with insufficient lymph node dissection are excluded. From 226 patients, 193 patients whose tumor was not T1 and whose both preoperative and postoperative data were present were included in the study. In particular, lymph node metastasis was not present in 81 patients. The ratio between the number of metastatic lymph nodes and total number of dissected lymph nodes was analysed to evaluate their influences on the disease outcome. Patients were divided into three groups according to the ratio (NR) between metastatic lymph nodes and total nodes dissected. The number of metastatic lymph nodes ranged from 0 to 43 (mean, 6.77±4.82) and the number of dissected total lymph nodes ranged from 15 to 93 (mean 27.13±6.91). There was no significant correlation between numbers of metastatic and dissected lymph nodes (p:0.142). Survival of patients at 5 years regardless of their stage was 54.1%, with a median survival of 23.24±4.18 months. According to regional nodal status (N) of the 8th edition of the AJCC, patients with N0 (n=81), pN1 (n=24), pN2 (n=31) and pN3 (n=67) showed survival rates at 5 years of 81.7%, 75.0%, 45.2% and 40.3%, respectively (p=0.009). Patients were stratified into NR0 (ratio 0%), NR1 (ratio 1-49%) and NR2 (ratio >50%). Their survival rates at 5 years were 81.7%, 53.5% and 36.1%, respectively (p=0.008). Metastatic lymph node ratio is an independent prognostic factor in survival regardless of the number dissected in the surgical process. The metastatic lymph node ratio has a more beneficial effect on disease-free and overall survival than the number of metastatic lymph nodes. If D2 dissection is done, metastatic lymph node ratio should be added to pathological TNM staging for a better foresight and for the prevention of stage migrations.

Factors related to compliance with adjuvant chemotherapy in patients with gastric cancer: A retrospective single-center study.

Adjuvant chemotherapy (AC) improves survival outcomes in patients with advanced gastric cancer (GC) after curative surgery; however, some patients do not receive or complete chemotherapy. This study aimed to identify factors related to patient compliance with chemotherapy after curative surgery for advanced GC. The data of patients who underwent curative gastrectomy for pathologic stage II-III GC between 2012 and 2016 were reviewed. Patients were divided into an AC completion group (group C), AC incompletion group (group I), and surgery-only group (group S). The AC regimen was either tegafur/gimeracil/oteracil (S-1) or capecitabine plus oxaliplatin (XELOX). The study enrolled 417 patients; group C had 222 patients, group I had 110, and group S had 85. The most common reason for not initiating AC was poor general condition (36.5%), while chemotherapy-related complications was the common reason for AC incompletion (43.6%). In multivariate analysis, age over 65 years, Eastern Cooperative Oncology Group performance status ≥1, Charlson comorbidity index ≥1, and the presence of postoperative complications were independent risk factors for not initiating AC (odds ratio: 4.32, 2.62, 1.84, and 2.17, respectively). Age over 65 years, longer postoperative stay, and XELOX regimen were significant risk factors for incompletion of AC (odds ratio: 2.68, 1.72, and 2.23, respectively). Old age, poor performance status, comorbidities, and postoperative complications, longer postoperative hospital stay, and XELOX regimen were associated with poor compliance with AC in GC patients. Clinicians can improve compliance with AC by managing postoperative complications and selecting the most appropriate treatment regimen.

Preoperative lymphocyte-to-monocyte ratio is the most predictive inflammatory response marker of survival in gastric cancer.

Systemic inflammatory responses play a key role in cancer progression, and detecting the predictive inflammatory response markers is needed. The present study explored inflammatory response markers capable of predicting survival in patients with gastric cancer. We enrolled 264 patients, who underwent curative gastrectomy for clinical stage (cStage) I-III gastric cancer between 2012 and 2015. The cut-off point of eight preoperative inflammatory response markers was determined by receiver operating characteristic (ROC) curve analysis. The marker with the highest Harrell's concordance index (C-index) was adopted for subsequent univariate and multivariate analyses using the Cox proportional-hazards model. Among eight representative inflammatory response markers, lymphocyte-to-monocyte ratio (LMR; cut-off point, 4.60) achieved the highest C-index (0.633). The 5-year survival rate was significantly worse in patients with LMR < 4.60 than in those with LMR ≥ 4.60 (67.5% versus 89.0%, P < 0.001). In multivariate analysis, LMR < 4.60 was identified as an independent prognostic factor (hazard ratio: 2.372; 95% confidence interval: 1.266-4.442; P = 0.007). In this study, LMR had the strongest ability to predict the survival of patients with gastric cancer among other inflammatory response markers, with lower LMRs being associated with poor survival following curative gastrectomy.

Impact of Preoperative Time Interval on Survival in Patients With Gastric Cancer.

A time interval between diagnosis and surgery for gastric cancer is necessary, although its impact on survival remains controversial. We evaluated the impact of preoperative time interval on survival in gastric cancer patients. We enrolled 332 patients who underwent curative gastrectomy for clinical stage (cStage) I-III gastric cancer between 2012 and 2015. We separately analyzed early- (cStage I) and advanced-stage (cStages II and III) patients. Early-stage patients were divided according to preoperative time interval: short (≤ 42days) and long (> 42days) groups. Advanced-stage patients were also divided into short (≤ 21days) and long (> 21days) groups. We compared the survival between the short and long groups in early- and advanced-stage patients. The median preoperative time interval was 29days, and no significant differences were found in patient characteristics between the short and long groups in early- and advanced-stage patients. In early-stage patients, the 5-year survival rates of the short and long groups were 86.5% and 88.4%, respectively (P = 0.917). In advanced-stage patients, the 5-year survival rates were 72.1% and 70.0%, respectively (P = 0.552). In multivariate analysis, a longer time interval was not selected as an independent prognostic factor in early- and advanced-stage patients. In this study, survival difference was not found based upon preoperative time interval. The results do not affirm the delay of treatment without reason, however, imperative extension of preoperative time interval may be justified from the standpoint of long-term survival.

Significance of a preoperative systemic immune-inflammation index as a predictor of postoperative survival outcomes in gastric cancer

BackgroundSince inflammation and the immune system contribute to the development and progression of malignancies, parameters that reflect a host’s immune-inflammatory status may be useful prognostic indicators of gastric cancer (GC). The present study examined the clinical significance of a preoperative systemic immune-inflammation index (SII) for predicting postoperative survival outcomes in GC.MethodsA total of 447 patients who underwent curative gastrectomy for GC were included in the present study. SII was calculated as platelet count × neutrophil count/lymphocyte count. The prognostic impact of preoperative SII was examined using univariate and multivariate analyses.ResultsPreoperative SII ranged between 105 and 4455 (median 474), and the optimal cutoff value for predicting overall survival (OS) was 395 based on a receiver operating characteristic curve. The 5-year OS rate of the SII ≥ 395 group was 80.0%, which was significantly worse than that (92.7%) of the SII < 395 group (p < 0.001). The multivariate analysis identified SII ≥ 395 (hazard ratio [HR] 2.95; 95% confidence interval [CI] 1.49–6.39; p = 0.001), heart disease (HR 2.14, 95% CI 1.07–4.07), C-reactive protein ≥ 0.5 (HR 2.45, 95% CI 1.15–4.94), pT4 (HR 4.46, 95% CI 2.44–8.14), and pN+ (HR 4.02, 95% CI 2.10–7.93) as independent predictors of worse OS. Peritoneal recurrence was more frequent in the high SII group than in the low SII group (p = 0.028).ConclusionPreoperative SII may be a useful predictor of postoperative survival outcomes in GC. The meticulous surveillance of GC relapse, particularly peritoneal dissemination, is necessary for patients with SII ≥ 395 even after curative gastrectomy.

Impact of skeletal muscle mass in patients with recurrent gastric cancer

BackgroundWe retrospectively examined the relationship among skeletal muscle mass index (SMI), prognosis, and chemotherapy side effects in patients with recurrent gastric cancer (RGC).MethodsSixty-seven patients who developed recurrence after undergoing curative gastrectomy for gastric cancer at Tottori University Hospital and received palliative chemotherapy were included in this study. Pretreatment computed tomography was performed to measure the skeletal muscle mass (SMM) and cross-sectional SMM at the third lumbar vertebra. We focused on haematologic toxicity (neutropenia, thrombocytopenia, and anaemia), febrile neutropenia, and gastrointestinal toxicity (diarrhoea, vomiting, and stomatitis) as the side effects of chemotherapy.ResultsMedian SMIs for males and females (43.9 and 34.7 cm2/m2, respectively) were used as cutoff values. The patients were classified into high (SMIHigh; n = 34) and low SMI groups (SMILow; n = 33). The SMILow group included more patients treated with monotherapy (P = 0.016) compared with the SMIHigh group, had a significantly lower number of chemotherapy lines (P = 0.049), and had a significantly higher incidence of grade 3 or 4 side effects (P = 0.010). The median survival rate was significantly higher in the SMIHigh group (17.8 vs 15.8 months; P = 0.034). In the univariate analysis, body mass index, SMI, histological type, and prognostic nutritional index were identified as prognostic indicators. The multivariate analysis identified SMI (P = 0.037) and histological type (P = 0.028) as independent prognostic factors.ConclusionThe incidence of grade 3 or 4 side effects was significantly higher in patients with SMILow RGC. SMI was a useful prognostic marker of RGC.

Laparoscopic gastrectomy for early and advanced gastric cancer in a western center: a propensity score-matched analysis.

The employment of laparoscopic gastrectomy (LG) in the management of gastric cancer (GC) is increasing. Despite recent results from randomized trials, its effectiveness and oncological results in different scenarios remain controversial, especially in western centers. The aim of this study was to compare the short-term outcomes and survival of LG with open gastrectomy (OG) for GC. We reviewed all GC patients who underwent curative gastrectomy from a prospective database. Propensity score-matched (PSM) analysis including 10 variables was conducted to reduce patient selection bias using a 1:1 case-control match. A total of 530 GC were eligible for inclusion (438 OG and 92 LG). Older age, lower hemoglobin levels, total gastrectomy, larger tumor size, greater depth of tumor invasion and advanced pTNM stage was more frequent in the OG group. After PMS analysis, 92 patients were matched in each group. All variables assigned in the score were well matched. LG group had a slightly higher number of retrieved lymph nodes (42.3 vs 37.6), however, without reaching statistical significance (p = 0.072). No differences were recorded about the frequency of major postoperative complications (POC) and mortality rates between OG and LG groups (12% vs 15.2%, p = 0.519, respectively). In survival analysis, after matching, there was no difference in survival between the two groups. Multivariate analysis showed that only ASA and pN stage were independent factor associated with survival after PSM. In conclusion, laparoscopic gastrectomy was a safe and effective surgical technique for gastric cancer, with short-term and oncological outcomes comparable to open surgery.

Effects of Preoperative Pyloric Stenosis on Outcomes and Nutritional Status in 73 Patients Following Curative Gastrectomy for Gastric Cancer: A Retrospective Study from a Single Center.

BackgroundThe aim of this study was to explore the potential impact of pyloric stenosis (PS) on the nutritional status, the incidence of postoperative complications, and the long-term prognosis of distal gastric cancer (GC) patients after curative resection.Material/MethodsWe retrospectively analyzed the data of 343 GC patients who underwent curative gastrectomy for gastric cancer between January 2010 and December 2013. All patients were divided into 2 groups according to the status of PS. Their clinical and pathological features, nutritional indicators, and incidence of postoperative complications were compared and potential prognostic factors were analyzed using the propensity score matching analysis (PSM).ResultsSeventy-four (21.6%) patients had PS. Patients with PS had worse survival outcomes than those without PS (χ2=21.369, P<0.001). Multivariate survival analysis demonstrated that PS, depth of invasion, and lymph node metastasis (all P<0.05) were the independent predictors of overall survival (OS). Patients with PS had significantly higher lymph node metastasis in No. 3, 4sb, 4d, 6, 8a, 9, and 14v lymph nodes. Patients with PS had significantly lower preoperative BMI, more weight loss, and lower prealbumin than those without PS. There were no significant differences between the 2 groups in postoperative complications, morbidity, or mortality.ConclusionsDistal GC patients with PS have poor clinicopathological and nutritional status and poor prognosis. However, PS does not increase surgery-related morbidity and mortality.

Favorable Outcomes of Neoadjuvant Chemotherapy and Limited Para-Aortic Lymph Node Dissection for Advanced Gastric Cancer with Para-aortic Lymph Node Metastasis.

Although para-aortic lymph node (PALN) metastasis from gastric cancer is a non-curative lesion, gastrectomy with complete PALN dissection (PAND) following neoadjuvant chemotherapy (NAC) is a tentative standard treatment in Japan, based on the results of a small-scale phase II clinical trial. However, whether complete PAND (C-PAND) is always necessary for such diseases is open to debate. Patients who received NAC followed by R0 gastrectomy for gastric cancer with clinical PALN metastasis at the Cancer Institute Hospital in Tokyo from 2005 to 2017 were reviewed in the present study. We assessed surgical findings and long-term outcomes. In total, 44 patients receiving gastrectomy with C-PAND (n = 22) or limited PAND (L-PAND; n = 22) were included. Operation time was significantly longer in the C-PAND than in the L-PAND groups (363min vs. 271min, P = 0.037). There was no difference between the two groups in the ypStage classification and pattern of recurrence. The 5-year overall survival (OS)and relapse-free survival (RFS) curves were higher in the L-PAND group than the C-PAND group, without reaching a significant difference. The 5-year OS (42.9% vs. 75.7%, p = 0.017) and RFS (14.3% vs. 48.6%, p = 0.002) were significantly worse in the group of three or more, than in the group of less than three pathological PALN metastasis, whereas increasing numbers of harvested PALN were not associated with improved survival. Curative gastrectomy with L-PAND following NAC for gastric cancer involving PALN may be an alternative treatment to C-PAND.

Long-term prognosis of patients with cancer-related genes detected in postoperative peritoneal washings obtained during curative gastrectomy

BackgroundCancer cells in intraoperative peritoneal washings (PW) indicate increased peritoneal recurrence. Detection of CEA or CK20 genes indicates poor prognosis. We assessed long-term prognosis of patients with amplification of cancer-related genes in PW obtained intraoperatively during curative gastric cancer surgery. MethodsPW was collected before and immediately after curative gastrectomy. CEA, CK20, TFF1, MUC2, and FABP1-mRNA were selected as marker genes for reverse transcription polymerase chain reaction. Peritoneal recurrence-free survival (PRFS) and overall survival (OS) after >7-year follow-up were examined using the Kaplan–Meier method. ResultsOf 138 patients who underwent gastrectomy with negative cytological findings at laparotomy, 80 patients showed negative cancer-related gene amplification in preoperative PW. Fifty-eight patients were excluded due to positive gene amplification, which suggested presence of preoperative peritoneal cancer cells. The 80 patients had mRNA amplification in PW after surgery. Amplification of multiple and single cancer-related marker genes was observed in 38 and 21 patients; 21 cases had marker-negative results. Five-year PRFS was 69.1%, 95.2%, and 100% in multi-marker-positive, single marker-positive, and marker-negative cases, respectively. Multi-marker-positive patients had significantly worse PRFS than the other groups (p < 0.05). Multivariate analysis in the Cox proportional hazards model identified multi-marker-positivity as an independent prognostic factor for PRFS (hazard ratio, 7.6; 95% confidence interval, 1.07–62.63; p = 0.046), and multi-marker-positive patients had significantly worse OS than other groups (p < 0.01). ConclusionMulti-marker cancer-related gene amplification in PW is associated with worse prognosis in PRFS and OS even after a long follow-up; PRFS can be stratified by the number of genes amplified.

Risk factors for recurrence in each pattern after curative gastrectomy for pStage II/III gastric cancer: An exploratory analysis of a randomized controlled trial (JCOG1001).

4052 Background: Peritoneal, lymph node, and hematogenous recurrence are frequently observed as patterns of recurrence after surgery for gastric cancer. However, the clinicopathological characteristics associated with each recurrence have rarely been comprehensively reported in a multicenter study. Understanding the risk factors for each pattern of recurrence would be helpful for the early detection of recurrence and the initiation of optimal treatment. This study investigated the risk factors for the first recurrence in each pattern after curative gastrectomy, using data from a multicenter randomized controlled trial (JCOG1001) that was designed to investigate the efficacy of bursectomy. Methods: Patients of 20-80 years of age, with cT3(SS)-T4a(SE) gastric carcinoma according to the 14th Japanese Classification of Gastric Carcinoma, with an ECOG PS of 0-1, and a body mass index of &lt; 30 kg/m2, and without bulky lymph nodes, Borrmann type 4 or large type 3 carcinoma were eligible for inclusion in JCOG1001. Of the 1204 patients who were enrolled in JCOG1001, 932 pStage II/III patients with a common histological type were included in this study. Risk factors for hematogenous, lymph node, and peritoneal patterns of recurrence were estimated by a multivariable Fine and Grey model considering death or site of recurrence other than the first site of recurrence as competing risks. Results: The overall rate of recurrence was 27.1%. Hematogenous recurrence was the most frequent pattern (12.3%), followed by peritoneal (11.2%) and lymph node (7.5%) recurrence. Differentiated type (HR, 1.818; 1.237-2.674; p = 0.0024), pT4 (in comparison to pT1-3, HR, 1.511; 95% CI, 1.011-2.257; p = 0.0440), and pN3 (in comparison to pN0-2, HR, 2.431; 95% CI, 1.635-3.616; p &lt; 0.0001) were associated with an increased incidence of hematogenous recurrence. Conversely, more than D2 lymphadenectomy reduced this pattern of recurrence (in comparison to D1+or D2 lymphadenectomy, HR, 0.575; 95% CI, 0.364-0.907; p = 0.0174). Peritoneal recurrence was significantly associated with large (≥5 cm) tumor (HR, 1.649; 95% CI, 1.034-2.629; p = 0.0356), pT4 (in comparison to pT1-3, HR, 3.222; 95% CI, 2.086-4.976; p &lt; 0.0001), pN3 (in comparison to pN0-2, HR, 1.865; 95% CI, 1.275-2.727; p = 0.0013), and undifferentiated type (HR, 2.674; 95% CI, 1.628-4.394; p = 0.0001). Extended lymph node metastasis (pN3) was the only risk factor (in comparison to pN0-2, HR, 8.030; 95% CI, 4.605-14.002; p &lt; 0.0001) for lymph node recurrence. Conclusions: The risk factors for recurrence differed according to the patterns of recurrence. Vigilant follow-up with an understanding of patterns of recurrence is required, especially for high-risk patients.

Influence of positive margins on tumour recurrence and overall survival after gastrectomy for gastric cancer.

Incidence of positive surgical margins after curative gastrectomy ranges from 1% to 20%. It has been suggested that positive surgical margin is an adverse prognosis factor, with a higher local recurrence and worse overall survival (OS). However, the management of these patients remains unclear. A total of 267 patients who underwent gastrectomy with curative intent between January 2010 and December 2018 in our centre were enrolled in this study. Post-operative histological analysis revealed positive resection margins in 18 patients (8%). Clinicopathological features and outcome of patients undergoing gastrectomy with negative and positive margins were compared. Patients with positive margins were associated with higher American Joint Committee on Cancer (AJCC) stage, T stage, N stage, median number of positive nodes, diffuse Lauren type, whole stomach involved and poorly differentiated tumours. Local recurrence was described in 50% of cases with positive margins. The multivariate analysis demonstrated that the TNM stage was the only independent prognostic factor associated with recurrence. OS for positive margins at 1, 3 and 5 years was 75%, 57% and 26%, respectively. The median survival in patients with positive margins was 38.33 versus 81.17 months for R0 patients (p=0.027). Multivariate analysis showed that age (hazard ratio [HR] 1.041, 95% confidence interval [CI] 1.02-1.07, sex (HR 2.00, 95% CI 1.22-3.30) and TNM stage (p < 0.001) were independent factors of OS. Positive resection margin was an indication of advanced and more aggressive disease rather than an independent prognosis factor for OS or recurrence in gastric cancer.

Metachronous port site, muscular and subcutaneous metastases from a gastric adenocarcinoma: a case report and review of articles

BackgroundPort site metastasis (PSM) after curative gastrectomy for gastric cancer and muscular metastasis from gastric cancer are rare manifestations. Similarly, subcutaneous metastasis from gastric cancer is rare, and muscular and subcutaneous metastases are associated with poor prognosis. We report a case of long-term survival in a patient who underwent curative resection of gastric cancer and repeated recurrence of port site, muscular and subcutaneous metastases from gastric cancer, treated by resection.Case presentationA 75-year-old man was diagnosed with gastric cancer and referred to our department. Upper endoscopy demonstrated a 5-cm circumferential ulcerated lesion at the cardia. Biopsy findings showed a poorly differentiated tubular adenocarcinoma. He underwent laparoscopic total gastrectomy with lymph node dissection, and pathologic examination revealed a moderately differentiated tubular adenocarcinoma stage T4aN1M0 and IIIA according to the UICC (Union for International Cancer Control) classification. He refused adjuvant chemotherapy and was only carefully observed. Twenty-three months after the primary gastrectomy, computed tomography (CT) revealed an irregular mass near the port site wounds. Then the patient underwent mass resection, and the pathological diagnosis was consistent with metastatic adenocarcinoma, located in the subcutaneous tissue at the port site wounds. Thirteen months after the second surgery, CT revealed an enhanced mass in the abdominal wall. Positron emission tomography (PET) CT showed an elevated uptake in the rectus abdominis muscle and a standardized uptake value (SUV) of 3.1. The patient underwent another mass resection, and the pathological diagnosis was consistent with metastatic adenocarcinoma in the rectus abdominis muscle. Thirty-five months after the third surgery, CT revealed a mass in the left gluteal subcutaneous region. Furthermore, PET-CT revealed a 35-mm mass with an elevated SUV of 9.6. Another mass resection procedure was performed, and the pathological diagnosis was consistent with metastatic adenocarcinoma in the subcutaneous tissue. Since tumor cells were present at the resection margin, additional radiation therapy was performed. The patient has survived 78 months after primary gastrectomy.ConclusionThe prognosis of muscular and subcutaneous metastases from gastric cancer is poor. However, if the metastatic tumor is solitary, surgical excision could be a feasible treatment option and might prolong survival.

Clinical significance of sarcoid-like reaction in lymph nodes of gastric cancer patients.

Although granulomatous formation (sarcoid-like reaction [SR]) similar to sarcoidosis occasionally occurs in regional lymph nodes of malignant tumors, the pathological significance of SR is unknown. We aimed to elucidate the clinicopathological significance and prognostic relevance of SR in gastric cancer. We evaluated 391 patients who underwent curative gastrectomy for gastric cancer between 2007 and 2016 at our hospital. The patients were divided into two groups according to presence of SR in lymph nodes, and clinicopathological factors and prognosis were compared between the two groups. SR was found in 67 (17.1%) of the 391 patients, and 332 (3.3%) of 10,149 lymph nodes examined. Regarding clinicopathological factors, SR-positive group showed significantly higher average age (p < 0.01) and numbers of differentiated tumors than SR-negative group (p < 0.05). Three-year overall survival rate in elderly patients aged ≥75 years was significantly more favorable in SR-positive group (n = 27, 85.2%) versus SR-negative group (n = 97, 63.4%) (p < 0.05). Immunohistochemical studies showed the predominant presence of CD68-positive macrophages for SR, with CD4/CD8-positive T cells and interleukin-10 also positive. The presence of SR in gastric cancer is frequent in elderly patients and might be a favorable indicator of prognosis. SR is suggested to reflect immune activation in the host.