R0 Resection For Gastric Cancer Research Articles

Predictive Role of Endoscopic Surveillance after Total Gastrectomy with R0 Resection for Gastric Cancer.

BackgroundEndoscopic surveillance after total gastrectomy (TG) for gastric cancer is routinely performed to detect tumor recurrence and postoperative adverse events. However, the reports on the clinical benefits of endoscopic surveillance are ambiguous. We investigated the clinical benefit of endoscopic surveillance after TG for gastric cancer.MethodsWe analyzed 848 patients who underwent TG with R0 resection for gastric cancer between 2011 and 2012 (380 early gastric cancer and 468 advanced gastric cancer) and underwent regular postoperative surveillance with endoscopy and abdominopelvic computed tomography (CT) with contrast.ResultsMedian follow-up periods were 58 months for both endoscopy (range, 3–96) and abdominopelvic CT (range, 1–96). Tumor recurrence occurred in 167 patients (19.7%), of whom seven (4.2%) were locoregional recurrences in the peri-anastomotic area (n = 5) or regional gastric lymph nodes (n = 2). Whereas the peri-anastomotic recurrences were detected by both endoscopy and abdominopelvic CT, regional lymph node recurrences were only detected by abdominopelvic CT. Out of the 23 events of postoperative adverse events, the majority (87%) were detected by radiologic examinations; three events of benign strictures in the anastomotic site were detected only by endoscopy.ConclusionEndoscopic surveillance did not have a significant role in detecting locoregional tumor recurrence and postoperative adverse events after TG with R0 resection for gastric cancer. Routine endoscopic surveillance after TG may be considered optional and performed according to the capacities of each clinical setting.

1843P Electro-acupuncture for quality of life in gastric cancer patients undergoing adjuvant chemotherapy

Gastrectomy followed by adjuvant chemotherapy (chemo) remains preferred strategy for local gastric cancer. However, quality of life (QoL) declines post-operatively, due to both surgery and chemotherapy. This pilot study (NCT03753399) aimed at evaluating the preliminary effect of electro-acupuncture (EA) for improving quality of life in gastric cancer patients undergoing adjuvant chemotherapy. Patients who has accepted R0 resection for gastric cancer, and who will receive adjuvant chemotherapy were randomly assigned to receive high-dose of EA (7 times each chemo-cycle for 3 cycles), low-dose of EA (3 times each chemo-cycle for 3 cycles), or no acupuncture. Functional Assessment of Cancer Therapy-Gastric (FACT-Ga) was reported by the patients at baseline and then once a week during the therapy. Primary endpoint was the total area under curves (AUCs) of FACT-Ga Trial Outcome Index (TOI) during the 3 cycles of chemotherapy, calculated by linear interpolation, among the groups. Secondary endpoints included the AUCs of FACT-Ga Gastric Cancer Subscale (GaCS), and FACT-Ga score among the groups. Of the randomized 66 patients, 45 (68.18%) were analyzed in the per-protocol set (PPS). Electro-acupuncture, both high-dose and low-dose, although not significantly, produced trend of QoL improvement. AUCs (21 days/cycle × 3 cycles), the higher, the better, of TOI in the PPS were 5360±1120, 5443±1313, and 4780±840 (p=0.188), of GaCS were 3273±591, 3261±757, and 2865±534 (p=0.126), and of FACT-Ga were 7731±1587, 7979±1702, and 7084 ±1183 (p=0.231), in high-dose EA group, low-dose EA group, and control group, respectively. When combining patients in the two EA groups, TOI (5402±1198 vs. 4780±840, p=0.048) and GaCS (3267±666 vs. 2865±534, p=0.041) AUCs of EA patients were significantly higher than those in control group. AUCs of FACT-Ga in EA patients were also higher than those in control group, although the difference was not statistically significant (7855±1620 vs. 7085±1183, p=0.074). Electro-acupuncture was associated with promising effect in improving quality of life during adjuvant chemotherapy in gastric cancer patients. Future adequately powered trial is needed to confirm the specific effect.

Early postoperative complications and risk factors in laparoscopic D2 radical gastrectomy for gastric cancer

Objective: To investigate the morbidity and treatment of early postoperative complications after laparoscopic D2 radical gastrectomy for gastric cancer, and to explore the risk factors. Methods: A case-control study was performed to retrospectively collect clinicopathological data of 764 patients undergoing laparoscopic D2 radical gastrectomy for gastric cancer at our department between January 2015 and December 2017. Patient inclusion criteria: (1) gastric cancer diagnosed by preoperative electronic gastroscopy and biopsy, and confirmed by postoperative pathology; (2) without invasion into adjacent organs by preoperative evaluation of tumors; (3) tumors without definite liver and distant metastasis; (4) R0 resection of gastric cancer and standard D2 lymph node dissection; (5) patients with informed consent. Exclusion criteria: (1) unperformed laparoscopic D2 radical resection; (2) other types of gastric tumor confirmed by pathology; (3) cases with incomplete clinical data. Complication occurring within two weeks after laparoscopic D2 gastrectomy was defined as early postoperative complication. Patients were divided into two groups: non-complication group (693 cases) and complication group (71 cases) according to the occurrence of complications after operation. The clinicopathological data of two groups were analyzed and compared with t test and χ(2) test, and the factors of P < 0.2 were included in the multivariate logistic regression model to analyze the risk factors of postoperative complications. Results: Of 764 patients, 71 (9.3%) developed early postoperative complications, with median onset time of 3 (1 to 11) days. Surgical complications accounted for 7.9% (60/764), including 13 cases (1.7%) of abdominal hemorrhage, 12 cases (1.6%) of anastomotic leakage, 10 cases (1.3%) of incision infection, 8 cases (1.0%) of anastomotic bleeding, 7 cases (0.9%) of gastric stump weakness, 4 cases (0.5%) of abdominal infection, 4 cases (0.5%) of duodenal stump leakage and 2 cases (0.3%) of small intestinal obstruction. Non-surgical complications accounted for 1.4% (11/764), including 6 cases (0.8%) of pulmonary infection and 5 cases (0.7%) of cardiovascular disease. Two cases (0.3%) died of sepsis caused by severe abdominal infection; 9 cases (1.2%) recovered after receiving the second operation, among whom 5 cases were abdominal hemorrhage, 2 cases were anastomotic leakage and 2 cases were duodenal stump leakage; the remaining patients were healed with conservative treatment. Compared with patients without complications, patients with complications had higher proportions of BMI ≥24 kg/m(2) [42.3% (30/71) vs. 24.2%(168/693), χ(2)=10.881, P=0.001], comorbity [64.8% (46/71) vs. 33.5% (232/693), χ(2)=27.277, P<0.001], combined organ resection [70.4% (50/71) vs. 20.5% (142/693), χ(2)=85.338, P<0.001], and pTNM stage of III [70.4% (50/71) vs. 40.1% (278/693), χ(2)=24.196, P<0.001], meanwhile had longer time to postoperative flatus [(4.2±2.1) days vs. (2.9±1.2) days, t=4.621, P=0.023], longer hospital stay [(34.6±12.6) days vs. (14.2±6.2) days, t=9.862, P<0.001] and higher hospitalization cost [(126.8±64.5) thousand yuan vs. (85.2±35.8) thousand yuan, t=11.235, P<0.001]. Multivariate analysis showed that BMI ≥24 kg/m(2) (OR=3.762, 95% CI: 1.960-8.783, P=0.035), accompanying disease (OR=8.620, 95% CI: 1.862-29.752, P<0.001), combined organ resection (OR=6.210, 95% CI: 1.357-21.568, P=0.026), and pTNM stage (OR=4.752, 95% CI: 1.214-12.658, P<0.001) were the independent risk factors of postoperative complications. Conclusions: Laparoscopic D2 radical gastrectomy is a safe and effective approach for gastric cancer. Most early postoperative complications can obtain satisfactory efficacy after conservative treatment. Perioperative management should be strengthened for those patients with high BMI, accompanying diseases, combined organ resection, and advanced pTNM stage.

ASO Author Reflections: Simplified Nomogram Predictive of Survival after R0 Resection for Gastric Cancer

ASO Author Reflections: Simplified Nomogram Predictive of Survival after R0 Resection for Gastric Cancer

Development and External Validation of a Simplified Nomogram Predicting Individual Survival After R0 Resection for Gastric Cancer: An International, Multicenter Study.

Previous studies have developed three nomograms for the individual prediction of overall survival after gastric cancer surgery. In this study, the performance of these nomograms was evaluated and compared with that of a simplified nomogram in a multinational cohort of patients. Clinical data from patients who underwent resection (R0) with curative intent for GC at three specialized centers (two from China and one from Italy) and data from the Surveillance, Epidemiology, and End Results database were retrospectively analyzed. The study analyzed 9810 patients, and the simplified nomogram was developed based on the following factors present in all models: age, sex, depth of invasion, and number of metastatic lymph nodes. In the decision curve analyses, the simplified nomogram demonstrated similar net benefit gains relative to previous models. The discriminative ability of the simplified nomogram was similar to those of the three existing nomograms, and calibration of the simplified nomogram resulted in a predicted survival similar to the actual survival. The predictive ability of the simplified nomogram was superior to that of the American Joint Committee on Cancer (AJCC) stage using Eastern and Western validation data (p < 0.01). Additionally, the simplified nomogram predicted the probabilities within each AJCC stage to illustrate the heterogeneity of risk within each stage. The novel simplified nomogram simplifies the assessment of individual survival after R0 resection for GC without sacrificing predictive ability. It also has potential for use with other databases and for clinical applications.

Long-Term Outcomes of Gastric Cancer Patients with Preoperative Sarcopenia.

There are few reports of long-term outcomes of gastric cancer patients with sarcopenia. The purpose of this study was to assess the impact of sarcopenia on long-term outcomes in gastric cancer patients who underwent curative resection. A total of 951 patients aged 65years or older who underwent R0 resection for gastric cancer were investigated. Sarcopenia was defined as a decreased arm muscle area < 38.05cm2 in men and < 27.87cm2 in women combined with a decline in grip strength to < 26 kgf in men and < 18 kgf in women. Of 951 patients, 111 (11.7%) were diagnosed with sarcopenia. Reduced surgery was performed significantly more frequently in patients with sarcopenia (p = 0.006). The incidence of eligible patients who received adjuvant chemotherapy was significantly lower in patients with sarcopenia than in those without sarcopenia (p = 0.030). Mortality due to gastric cancer and aging-associated multiple organ failure rates without obvious diseases were higher in patients with sarcopenia (p = 0.036 and p < 0.001, respectively). Overall survival (OS) and cause-specific survival (CSS) were significantly worse in patients with sarcopenia (p < 0.001 and p = 0.005, respectively). Multivariate analysis for OS and CSS revealed that sarcopenia was an independent prognostic factor in gastric cancer patients (p < 0.001 and p = 0.043, respectively). Sarcopenia is related to poor survival in gastric cancer patients and appears to be a significant negative prognostic factor in patients with gastric cancer who underwent curative resection.

Lymph node ratio as a prognostic factor in gastric cancer patients following D1 resection. Comparison with the current TNM staging system

IntroductionNodal ratio (NR) has been demonstrated to be an independent prognostic factor in patients with gastric cancer. We evaluated the prognostic role of NR comparing it with the current TNM (2010) classification in gastric cancer patients treated with curative (R0) D1 resection. Materials and methodsWe retrospectively reviewed 110 patients who underwent R0 resection for gastric cancer at University Hospital of Larissa between 2002 and 2011. All patients had a D1 lymphadenectomy plus the nodes along the left gastric artery. Factors affecting survival as well as correlations between the N status, NR status and resected nodes were investigated. ResultsIn univariate analysis the N and NR status but not the numbers of retrieved nodes were significant prognostic factors. Inside N1 and N2 categories, patients with different NR groups were present and survival of some of these subpopulations was statistically different at long-rank test. There was a correlation between the nodes retrieved and N status but not with the NR category. In multivariate analysis both N status (HR=1.45; 95% C.I. = 1.19–1.89) and NR (HR=4.53; 95% C.I. = 1.86–11.03) found to be independent prognostic factors of survival. ConclusionPrognostic significance of N status and NR status was comparable. Unlike N status, NR is independent by the number of resected nodes, and therefore it is particularly useful in case of conventional lymphadenectomy.

A Novel Prognostic Scoring System Based on Preoperative Sarcopenia Predicts the Long-Term Outcome for Patients After R0 Resection for Gastric Cancer: Experiences of a High-Volume Center.

The relationship between sarcopenia and prognosis of gastric cancer (GC) is unclear. This study aimed to develop a prognostic scoring system combining sarcopenia with preoperative clinical parameters for patients with GC to predict 3-year overall survival (OS) and 3-year recurrence-free survival (RFS). In this study, 924 patients with GC who underwent radical gastrectomy were retrospectively analyzed. The data were divided into a training set and a validation set. Sarcopenia was diagnosed by the cutoff value of the skeletal muscle index (SMI) obtained by X-tile software. The study used COX regression to identify preoperative risk factors associated with 3-year OS and RFS. In the training set, 103 patients (14.8%) were sarcopenic based on the cutoff value of the SMI (32.5cm2/m2 for men and 28.6cm2/m2 for women). Multivariate analysis showed the following preoperative risk factors for the training set: sarcopenia and preoperative T (cT) and N (cN) stages. A prognostic scoring system was developed based on these findings. The 3-year OS rates were 89% for the low-risk patients, 77.9% for the intermediate-risk patients, and 54.8% for the high-risk patients (P<0.001), and the 3-year RFS rates were respectively 86.9, 75.3 and 49.3% (P<0.001). The area under the receiver operating characteristic curves were 0.708 for the 3-year OS rates and 0.713 for the 3-year RFS rates. The observed and predicted incidence rates for 3-year OS and RFS in the validation set did not differ significantly. The prognostic scoring system combining sarcopenia with the cT and cN system can accurately predict 3-year OS and RFS rates after radical gastrectomy for GC.

Impact of High Altitude on Clinicopathological Features and Prognosis after R0 Resection for Gastric Cancer: A Population-Based Multicenter Study.

Geographic variation has an important role in both carcinogenesis and prognosis of gastric cancer (GC). High altitude is a special hypoxic environment that is also correlated with the occurrence of GC. Different onset features and prognoses of GC in high altitude with respect to plains are rarely reported and remain unknown. This multicenter study compared different clinicopathological characteristics and prognoses of patients with resected GC who were from locations of both high altitudes and plains in China. From December 2009 to December 2011, patients with resected GC were retrospectively recruited at four centers located at high altitudes and the plains. Clinicopathological data were analyzed to explore the differences between the two groups. The Cox proportional-hazards model was used to investigate the prognostic factors for GC and estimate the independent impact of altitude on long-term survival after adjusting for covariates. Noncardia GC, from a moderate to well tumor grade, was more common in patients from high altitudes. Moreover, a higher proportion of moderate to well and moderate tumor grade and younger age of onset was found in patients with noncardia GC coming from high altitudes. Different overall survival (OS) presented in noncardia GC rather than cardia GC, with 69.94% GC-related 3-yr OS in high altitude versus 75.23% in the plains. High altitude was confirmed as a significant prognostic factor for noncardia GC (the hazard ratio for high altitude vs. plains was 1:50, with a 95% confidence interval; 1.06-1.82, p = 0.018) through a multivariate Cox proportional-hazards model analysis. This prognostic value was independent of all other factors. High altitude has an important role in clinicopathological features and prognosis of GC. Improvements in GC diagnosis and management at high altitudes are urgently needed.

Predictive pre-treatment value of the Prognostic Nutritional Index on survival in gastric carcinoma

The Prognostic Nutritional Index (PNI) combines the values of circulating lymphocytes and serum albumin and, in the Asian literature; it has been related with the prognosis following R0 resection of gastric cancer. No results are available in Western countries. We study the possible independent prognostic value, at the moment of the tumour's diagnosis, of PNI on survival. We review 234 consecutive gastric carcinomas, calculating global survival and tumour-specific survival. We considered pre-treatment PNI values of < 40 to be pathological. We carried out a univariate and multivariate analysis of cases of survival according to PNI, including the following adjustment variables: age > 70 years, ASA anaesthetic at the time of diagnosis, size of the neoplasia > 5cm, macroscopic type, undifferentiated degree and TNM clinical stage through echoendoscopy and/or CAT. The univariate analysis registered greater global and specific survival in cases with PNI ≥ 40 versus PNI < 40: [HR = 2.28; CI 95% = (1.60-3.26); p< 0.001] and [HR = 2.35; CI 95% = (1.63-3.39); p< 0.001], respectively. The multivariate analysis confirmed a better independent prognosis in cases with OI ≥ 40: global survival: [HR = 1.48; CI 95% = (1.02-2.16); p = 0.040], specific survival: [HR = 1.51; CI 95% = (1.03-2.23); p = 0.036]. At the moment of diagnosis of gastric cancer and including all registered cases, a PNI ≥ 40 is accompanied by a signifi-cantly greater global and tumour-specific survival. In our series, this better prognosis is independent of the patient's age group, his/her ASA classification, the size and degree of differentiation of the neoplasia and its TNM clinical stage.

Lymph-Node Ratio Classification Strongly Correlates with Cancer Survivals of Patients Who Underwent R0 Resection for Gastric Cancer with More than 15 Nodes Harvested

Background: During the last few years, the gastric cancer nodal staging has been extensively revised. Lately, a new system emerged in this field with the purpose of implementing the prognostic stratification: the lymph-node ratio (LNR). The aim of this study was to investigate the prognostic value of the LNR in relation to cancer survivors undergoing resection for gastric adenocarcinoma. Methods: Off 227 patients undergoing surgical resection for gastric cancer at our Department, 129 curative gastric resections with more than 15 nodes harvested were selected. The LNR was calculated and patients were stratified into 6 subgroups based on the ratio values. The subgroups were compared for data analysis. Survivals were calculated by the Kaplan-Meier method, and the mean follow-up period was 40 months. ROC curves were calculated in order to analyze the performance of the LNR system. Results: LNR stratification correlated with the stage of the disease, with the rate of patients undergoing chemotherapy and patients presenting with a relapse of disease at follow-up. Moreover, an increased ratio correlated with a worse overall, a disease-free and a disease-specific survival of the patients. The ROC curves documented a significant performance of the stratification system with the endpoints of disease-free and disease-specific survivals. Conclusion: LNR stratification correlated with cancer-related survivals in our case series. It is a reliable system that might improve current nodal staging and thereby the identification of patients with a higher risk of recurrence or cancer-related mortality.

Impact of infectious complications on gastric cancer recurrence

Postoperative infectious complications increase disease recurrence in colorectal cancer patients. We herein investigated the impact of infectious complications on gastric cancer recurrence after curative surgery. In total, 502 patients who underwent R0 resection for gastric cancer were reviewed. Patients were classified into those with infectious complications (IC group) and those without infectious complications (NO group). The risk factors for recurrence-free survival (RFS) were identified. Infectious complications, which occurred in 52 patients (10.4%), included pneumonia, ileus with a systemic inflammatory reaction, anastomotic leakage, and intraperitoneal abscess. The overall 5-year RFS rate was 83% in the NO group and 58% in the IC group (p = 0.000). Multivariate analysis demonstrated that age, ASA score, stage, and infectious complications were significant predictors of RFS. Infectious complications were a risk factor for gastric cancer recurrence. To avoid causing infectious complications, the surgical procedure, surgical strategy, and perioperative care should be carefully planned.

Performance of a Nomogram Predicting Disease-Specific Survival After an R0 Resection for Gastric Cancer in Patients Receiving Postoperative Chemoradiation Therapy

The internationally validated Memorial Sloan-Kettering Cancer Center (MSKCC) gastric carcinoma nomogram was based on patients who underwent curative (R0) gastrectomy, without any other therapy. The purpose of the current study was to assess the performance of this gastric cancer nomogram in patients who received chemoradiation therapy after an R0 resection for gastric cancer. In a combined dataset of 76 patients from the Netherlands Cancer Institute (NKI), and 63 patients from MSKCC, who received postoperative chemoradiation therapy (CRT) after an R0 gastrectomy, the nomogram was validated by means of the concordance index (CI) and a calibration plot. The concordance index for the nomogram was 0.64, which was lower than the CI of the nomogram for patients who received no adjuvant therapy (0.80). In the calibration plot, observed survival was approximately 20% higher than the nomogram-predicted survival for patients receiving postoperative CRT. The MSKCC gastric carcinoma nomogram significantly underpredicted survival for patients in the current study, suggesting an impact of postoperative CRT on survival in patients who underwent an R0 resection for gastric cancer, which has been demonstrated by randomized controlled trials. This analysis stresses the need for updating nomograms with the incorporation of multimodal strategies.

Validation of the Memorial Sloan-Kettering Cancer Center Nomogram to Predict Disease-Specific Survival after R0 Resection in a Chinese Gastric Cancer Population

BackgroundPrediction of disease-specific survival (DSS) for individual patient with gastric cancer after R0 resection remains a clinical concern. Since the clinicopathologic characteristics of gastric cancer vary widely between China and western countries, this study is to evaluate a nomogram from Memorial Sloan-Kettering Cancer Center (MSKCC) for predicting the probability of DSS in patients with gastric cancer from a Chinese cohort.MethodsFrom 1998 to 2007, clinical data of 979 patients with gastric cancer who underwent R0 resection were retrospectively collected from Peking University Cancer Hospital & Institute and used for external validation. The performance of the MSKCC nomogram in our population was assessed using concordance index (C-index) and calibration plot.ResultsThe C-index for the MSKCC predictive nomogram was 0.74 in the Chinese cohort, compared with 0.69 for American Joint Committee on Cancer (AJCC) staging system (P<0.0001). This suggests that the discriminating value of MSKCC nomogram is superior to AJCC staging system for prognostic prediction in the Chinese population. Calibration plots showed that the actual survival of Chinese patients corresponded closely to the MSKCC nonogram-predicted survival probabilities. Moreover, MSKCC nomogram predictions demonstrated the heterogeneity of survival in stage IIA/IIB/IIIA/IIIB disease of the Chinese patients.ConclusionIn this study, we externally validated MSKCC nomogram for predicting the probability of 5- and 9-year DSS after R0 resection for gastric cancer in a Chinese population. The MSKCC nomogram performed well with good discrimination and calibration. The MSKCC nomogram improved individualized predictions of survival, and may assist Chinese clinicians and patients in individual follow-up scheduling, and decision making with regard to various treatment options.

Can the ratio of metastatic to examined lymph nodes (N ratio) be used as an independent prognostic factor in patients with gastric cancer? Is the hypothetical TRM (tumor-ratio-metastasis) staging system an alternative to the TNM (tumor-node-metastasis) staging system?

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Ilhan E, Zengel B, Simsek H, Canpolat S, Yildirim M. Can the ratio of metastatic to examined lymph nodes (N ratio) be used as an independent prognostic factor in patients with gastric cancer? Is the hypothetical TRM (tumor-ratio-metastasis) staging system an alternative to the TNM (tumor-node-metastasis) staging system?. Gastroenterology Review/Przegląd Gastroenterologiczny. 2013;8(4):247-256. doi:10.5114/pg.2013.37488. APA Ilhan, E., Zengel, B., Simsek, H., Canpolat, S., & Yildirim, M. (2013). Can the ratio of metastatic to examined lymph nodes (N ratio) be used as an independent prognostic factor in patients with gastric cancer? Is the hypothetical TRM (tumor-ratio-metastasis) staging system an alternative to the TNM (tumor-node-metastasis) staging system?. Gastroenterology Review/Przegląd Gastroenterologiczny, 8(4), 247-256. https://doi.org/10.5114/pg.2013.37488 Chicago Ilhan, Enver, Baha Zengel, Hatice Simsek, Selin Canpolat, and Mehmet Yildirim. 2013. "Can the ratio of metastatic to examined lymph nodes (N ratio) be used as an independent prognostic factor in patients with gastric cancer? Is the hypothetical TRM (tumor-ratio-metastasis) staging system an alternative to the TNM (tumor-node-metastasis) staging system?". Gastroenterology Review/Przegląd Gastroenterologiczny 8 (4): 247-256. doi:10.5114/pg.2013.37488. Harvard Ilhan, E., Zengel, B., Simsek, H., Canpolat, S., and Yildirim, M. (2013). Can the ratio of metastatic to examined lymph nodes (N ratio) be used as an independent prognostic factor in patients with gastric cancer? Is the hypothetical TRM (tumor-ratio-metastasis) staging system an alternative to the TNM (tumor-node-metastasis) staging system?. Gastroenterology Review/Przegląd Gastroenterologiczny, 8(4), pp.247-256. https://doi.org/10.5114/pg.2013.37488 MLA Ilhan, Enver et al. "Can the ratio of metastatic to examined lymph nodes (N ratio) be used as an independent prognostic factor in patients with gastric cancer? Is the hypothetical TRM (tumor-ratio-metastasis) staging system an alternative to the TNM (tumor-node-metastasis) staging system?." Gastroenterology Review/Przegląd Gastroenterologiczny, vol. 8, no. 4, 2013, pp. 247-256. doi:10.5114/pg.2013.37488. Vancouver Ilhan E, Zengel B, Simsek H, Canpolat S, Yildirim M. Can the ratio of metastatic to examined lymph nodes (N ratio) be used as an independent prognostic factor in patients with gastric cancer? Is the hypothetical TRM (tumor-ratio-metastasis) staging system an alternative to the TNM (tumor-node-metastasis) staging system?. Gastroenterology Review/Przegląd Gastroenterologiczny. 2013;8(4):247-256. doi:10.5114/pg.2013.37488.

Performance of a Nomogram Predicting Disease-specific Survival After an R0 Resection for Gastric Cancer in Patients Receiving Postoperative Chemoradiation therapy

The internationally validated Memorial Sloan-Kettering Cancer Center (MSKCC) gastric cancer nomogram was based on patients who underwent curative (R0) gastrectomy, without any other therapy. The purpose of the current study was to assess the performance of this gastric cancer nomogram in patients who received chemoradiation therapy after an R0 resection for gastric cancer.

Changing clinical and pathological features of gastric cancer over time

The aim of the present multicentre observational study was to evaluate potential changes in clinical and pathological features of patients with gastric cancer (GC) treated in a 15-year interval. A centralized prospective database including clinical, surgical, pathological and follow-up data from 2822 patients who had resection of a primary GC was analysed. The analysis focused on three periods: 1991-1995 (period 1), 1996-2000 (period 2) and 2001-2005 (period 3). Surgical procedure, pathological classification and follow-up were standardized among centres. The number of resections decreased from 1024 in period 1 to 955 and 843 in periods 2 and 3 respectively. More advanced stages and a smaller number of intestinal-type tumours of the distal third were observed over time. Five-year survival rates after R0 resection (2320 patients) did not change over time (overall: 56·6 and 51·2 per cent in periods 1 and 3; disease-free: 66·8 and 61·1 per cent respectively). Decreases in survival in more recent years were related particularly to more advanced stage, distal tumours and tumours in women. Multivariable analysis showed a lower probability of overall and disease-free survival in the most recent interval: hazard ratio 1·22 (95 per cent confidence interval 1·06 to 1·40) and 1·29 (1·06 to 1·58) respectively compared with period 1. Recurrent tumours were more frequently peritoneal rather than locoregional. Overall and disease-free survival rates after R0 resection of GC were unchanged over time.

Conditional survival nomogram after an R0 resection for gastric cancer.

11 Background: The risk of dying of cancer is highest in the first two years after a curative resection for gastric cancer. Therefore, the prognosis of patients who did not recur in the first two years is improved because they survived this critical period, a phenomenon called conditional survival. The US-derived gastric cancer nomogram predicts disease-specific survival (DSS) based on pathological variables. However, a disease-free interval after surgery, which improves the prognosis, is not captured by the nomogram. Therefore, it has only been used directly after surgery and not in the follow-up setting. The purposes of this study were to develop a conditional survival nomogram for 1, 2 and 3-year survivors (step 1) and to test if the introduction of follow-up variables would improve predictive accuracy of the nomogram in the follow-up setting (step 2). Methods: In a combined US-Dutch population of 1642 patients who underwent an R0 resection for gastric cancer and for whom the old nomogram variables were available, a conditional survival nomogram based on the original variables was developed for one (N=1147), two (N=879) and three (N=721) year survivors (step 1). To improve predictive accuracy in the follow-up setting, weight loss, performance status (PS), hemoglobin (HGB), and albumin (ALB) at one year after resection were retrospectively collected and added to the baseline variables in a new nomogram (step 2). Results: The conditional survival nomograms for 1, 2 and 3-year survivors (step 1) showed a high predictive accuracy in the calibration plots. Surviving one, two and three years shows a median improvement of 5-year DSS of 4%, 9% and 14% respectively. The introduction of weight loss, PS, HGB, and ALB at one year after surgery (step 2) did not improve this nomogram, but availability of these variables was limited. Conclusions: A strongly predictive conditional survival nomogram was developed, giving an improved prognosis for 1, 2 and 3-year survivors of gastric cancer. Introduction of variables available at one year after resection did not further improve this nomogram. This might be caused by the limited availability of follow-up data, as well as the strong predictive accuracy of the original variables. No significant financial relationships to disclose.

Risk of recurrence after laparoscopy-assisted radical gastrectomy for gastric cancer performed by a single surgeon

The risk of recurrence after laparoscopy-assisted radical gastrectomy (LAG) was investigated. Clinical data of 398 consecutive patients who underwent radical gastrectomy with R0 resection for gastric cancer at Gyeongsang National University Hospital between January 2005 and December 2007 were reviewed retrospectively. Of the patients, 65.4% (n = 261) and 34.6% (n = 138) underwent LAG and open radical gastrectomy (OG), respectively. Of the LAG cases, 73.2% (n = 192), 10.7% (n = 28), 12.6% (n = 33), and 3.1% (n = 8) had stage I, II, III, and IV gastric cancer, respectively. All patients were followed up for a mean of 36.8 ± 13.7 months, and 14.6% (n = 58) had recurrence during the follow-up period. Univariate analysis revealed that tumor size, tumor-node-metastasis (TNM) stage, method of approach (LAG versus OG), and operation type were associated significantly with recurrence. Multivariate analysis revealed that only high TNM stage was significantly associated with recurrence (P = 0.00). While patients who underwent OG had higher incidence of recurrence than patients who underwent LAG, OG was not significantly associated with recurrence on multivariate analysis (P = 0.06). LAG and OG did not differ significantly in terms of recurrence, even when used in advanced gastric cancer cases. Multivariate analysis revealed that high TNM stage was significantly associated with recurrence. Thus, LAG appears to be a safe and feasible procedure that has the potential to be an alternative to open surgery, even for advanced gastric cancer.

High preoperative serum vascular endothelial growth factor levels predict poor clinical outcome after curative resection of gastric cancer

Tumour vascular endothelial growth factor (VEGF) and tumour urokinase-type plasminogen activator (uPA) are prognostic factors in gastric cancer but surgical specimens are required for testing. The prognostic value of preoperative serum VEGF (s-VEGF) and serum uPA (s-uPA) levels was evaluated in patients undergoing potentially curative (R0) gastric cancer resection. Concentrations of s-VEGF and s-uPA were measured 97 patients with gastric cancer and 20 controls. Angiogenesis was measured in vitro based on human endothelial cell tube formation. Levels of s-VEGF were higher in patients with gastric cancer than controls (median 288 versus 189 pg/ml respectively; P = 0.002). They were associated with pathological tumour node metastasis (pTNM) stage, pT, pN, lymph node ratio and perineural invasion, and correlated with platelet counts. In multivariable analysis, s-VEGF over 320 pg/ml was the only preoperative predictor of both recurrence and disease-specific survival. Serum from patients with raised s-VEGF levels enhanced angiogenesis in vitro significantly more than serum from those with a s-VEGF level of 320 pg/ml or less. High preoperative s-VEGF level is an independent prognostic factor for recurrence and survival after R0 resection of gastric cancer. This may provide a useful guide to decision making regarding neoadjuvant and adjuvant therapies.