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8 pages, 819 KiB

Open AccessArticle

Is There Any Role for Super-Extended Limphadenectomy in Advanced Gastric Cancer? Results of an Observational Study from a Western High Volume Center

by Maria Bencivenga, Giuseppe Verlato, Valentina Mengardo, Lorenzo Scorsone, Michele Sacco, Lorena Torroni, Simone Giacopuzzi and Giovanni de Manzoni

J. Clin. Med. 2019, 8(11), 1799; https://doi.org/10.3390/jcm8111799 - 27 Oct 2019

Cited by 8 | Viewed by 2698

Abstract

Background: Although the Japan Clinical Oncology Group (JCOG) 9501 trial did not find that prophylactic D3 lymphadenectomy led to any survival advantage over D2 lymphadenectomy, it did find that the prognosis of subserosal and N0 gastric cancer patients improved. The aim of this [...] Read more.

Background: Although the Japan Clinical Oncology Group (JCOG) 9501 trial did not find that prophylactic D3 lymphadenectomy led to any survival advantage over D2 lymphadenectomy, it did find that the prognosis of subserosal and N0 gastric cancer patients improved. The aim of this retrospective observational study was to compare survival after D2 or D3 lymphadenectomy in different patient subgroups. Methods: The study considered all of the patients who underwent D2 or D3 lymphadenectomy at a high-volume center in Verona (Italy) between 1992 and 2011. After excluding patients with Bormann IV or neuroendocrine tumors, early gastric cancers, or non-curative resections, the analysis involved 301 R0 patients: 100 who underwent D2, and 201 who underwent D3 lymphadenectomy. Post-operative deaths and deaths due to recurrences were considered as terminal events in the survival analysis. Results: The D2 patients were significantly older than the D3 patients at baseline (69.8 ± 2.3 vs. 62.2 ± 10.7 years). The median number of retrieved nodes was 29 (interquartile range: 24.5–39) after D2, and 43 (34–52) after D3. The five-year disease-related survival rate was similar after D2 (44%, 95% confidence interval (CI) 34–54%) and D3 (41%, 34–48%) (p = 0.766). A Cox model controlling for sex, age, tumor site, Laurén histology, and T and N stages showed that the risk of cancer-related death after D3 was similar to that recorded after D2 (hazard ratio 0.97, 95% CI 0.67–1.42). There was a significant interaction between the T status and the extension of the lymphadenectomy (p = 0.012), with the prognosis being better after D2 in T2 and T4b patients, and after D3 in T3 patients. Conclusions: The findings of this study suggest that D3 lymphadenectomy is not routinely indicated for patients with advanced gastric cancer, although differences in survival after D3 across T tiers deserve further consideration. Full article

(This article belongs to the Special Issue Surgical Management of Gastric Cancer)

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10 pages, 714 KiB

Open AccessArticle

Significance of the Glasgow Prognostic Score in Predicting the Postoperative Outcome of Patients with Stage III Gastric Cancer

by Shun-Wen Hsueh, Keng-Hao Liu, Chia-Yen Hung, Yung-Chia Kuo, Chun-Yi Tsai, Jun-Te Hsu, Yu-Shin Hung, Ngan-Ming Tsang and Wen-Chi Chou

J. Clin. Med. 2019, 8(9), 1448; https://doi.org/10.3390/jcm8091448 - 12 Sep 2019

Cited by 21 | Viewed by 2357

Abstract

This study aimed at investigating the ability of a preoperative Glasgow prognostic score (GPS) to predict postoperative complications and survival outcomes in patients with stage III gastric cancer undergoing D2 gastrectomy. We retrospectively reviewed data from 272 such patients, treated between 2010 and [...] Read more.

This study aimed at investigating the ability of a preoperative Glasgow prognostic score (GPS) to predict postoperative complications and survival outcomes in patients with stage III gastric cancer undergoing D2 gastrectomy. We retrospectively reviewed data from 272 such patients, treated between 2010 and 2016, at a Taiwanese medical center. The patients were categorized according to their GPS. In total, 36.8%, 48.5%, and 14.7% of the patients were assigned to groups with a GPS of 0, 1, and 2, respectively. Overall surgical complication rates in these groups were 30%, 45.5%, and 52.5% (p = 0.016); postoperative intensive care unit admission rates were 10%, 14.4%, and 22.5% (p = 0.15); postoperative 30-day re-admission rates were 6%, 15.2%, and 20% (p = 0.034); and the in-hospital mortality rates were 1.0%, 1.5%, and 10.0%, respectively (p = 0.006). The median survival times of the patients were 42.9 months (95% confidence interval [CI], 29.1–56.6), 22.6 months (95% CI, 19.3–25.8), and 16.6 months (95% CI, 7.8–25.4), respectively (p< 0.001). A significant correlation was observed between the preoperative GPS, short-term postoperative complications, and long-term survival outcomes in patients with gastric cancer undergoing D2 gastrectomy. These findings recommend the usage of the GPS as a predictive and prognostic factor in patients with gastric cancer considering surgical resection. Full article

(This article belongs to the Special Issue Surgical Management of Gastric Cancer)

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10 pages, 966 KiB

Open AccessArticle

A Lesion-Based Convolutional Neural Network Improves Endoscopic Detection and Depth Prediction of Early Gastric Cancer

by Hong Jin Yoon, Seunghyup Kim, Jie-Hyun Kim, Ji-Soo Keum, Sang-Il Oh, Junik Jo, Jaeyoung Chun, Young Hoon Youn, Hyojin Park, In Gyu Kwon, Seung Ho Choi and Sung Hoon Noh

J. Clin. Med. 2019, 8(9), 1310; https://doi.org/10.3390/jcm8091310 - 26 Aug 2019

Cited by 95 | Viewed by 6153

Abstract

In early gastric cancer (EGC), tumor invasion depth is an important factor for determining the treatment method. However, as endoscopic ultrasonography has limitations when measuring the exact depth in a clinical setting as endoscopists often depend on gross findings and personal experience. The [...] Read more.

In early gastric cancer (EGC), tumor invasion depth is an important factor for determining the treatment method. However, as endoscopic ultrasonography has limitations when measuring the exact depth in a clinical setting as endoscopists often depend on gross findings and personal experience. The present study aimed to develop a model optimized for EGC detection and depth prediction, and we investigated factors affecting artificial intelligence (AI) diagnosis. We employed a visual geometry group(VGG)-16 model for the classification of endoscopic images as EGC (T1a or T1b) or non-EGC. To induce the model to activate EGC regions during training, we proposed a novel loss function that simultaneously measured classification and localization errors. We experimented with 11,539 endoscopic images (896 T1a-EGC, 809 T1b-EGC, and 9834 non-EGC). The areas under the curves of receiver operating characteristic curves for EGC detection and depth prediction were 0.981 and 0.851, respectively. Among the factors affecting AI prediction of tumor depth, only histologic differentiation was significantly associated, where undifferentiated-type histology exhibited a lower AI accuracy. Thus, the lesion-based model is an appropriate training method for AI in EGC. However, further improvements and validation are required, especially for undifferentiated-type histology. Full article

(This article belongs to the Special Issue Surgical Management of Gastric Cancer)

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14 pages, 3273 KiB

Open AccessArticle

Hybrid Minimally Invasive Esophagectomy–Surgical Technique and Results

by Jasmina Kuvendjiska, Goran Marjanovic, Torben Glatz, Birte Kulemann and Jens Hoeppner

J. Clin. Med. 2019, 8(7), 978; https://doi.org/10.3390/jcm8070978 - 05 Jul 2019

Cited by 10 | Viewed by 3448

Abstract

Background: Hybrid minimally invasive esophagectomy (HMIE) has been proven to be superior when compared with open esophagectomy, with a significant reduction of postoperative morbidity. In HMIE, the laparotomy is replaced by a minimally invasive laparoscopic approach. The radical mediastinal resection plus reconstruction is [...] Read more.

Background: Hybrid minimally invasive esophagectomy (HMIE) has been proven to be superior when compared with open esophagectomy, with a significant reduction of postoperative morbidity. In HMIE, the laparotomy is replaced by a minimally invasive laparoscopic approach. The radical mediastinal resection plus reconstruction is performed by a thoracic approach through a muscle-sparing thoracotomy. In this instructional article, we describe the surgical technique of HMIE in detail in order to facilitate possible adoption of the procedure by other surgeons. In addition, we give the monocentric results of our own practice. Methods: Between 2013 and 2018, HMIE was performed in 157 patients. The morbidity and mortality data of the procedure is shown in a retrospective monocentric analysis. Results: Overall, 54% of patients had at least one perioperative complication. Anastomotic leak was evident in 1.9%, and a single patient had focal conduit necrosis of the gastric pull-up. Postoperative pulmonary morbidity was 31%. Pneumonia was found in 17%. The 90 day mortality was 2.5%. Wound infection rate was 3%, and delayed gastric emptying occurred in 17% of patients. In follow up, 12.7% presented with diaphragmatic herniation of the bowel, requiring laparoscopic hernia reduction and hiatal reconstruction and colopexy several months after surgery. Conclusion: HMIE is a highly reliable technique, not only for the resection part but especially in terms of safety in reconstruction and anastomosis. For esophageal surgeons with experience in minimally invasive anti-reflux procedures and obesity surgery, HMIE is easy and fast to learn and adopt. Full article

(This article belongs to the Special Issue Surgical Management of Gastric Cancer)

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13 pages, 2592 KiB

Open AccessArticle

Association between Interleukin-6 Levels and Perioperative Fatigue in Gastric Adenocarcinoma Patients

by Jin-Ming Wu, Hui-Ting Yang, Te-Wei Ho, Shiow-Ching Shun and Ming-Tsan Lin

J. Clin. Med. 2019, 8(4), 543; https://doi.org/10.3390/jcm8040543 - 20 Apr 2019

Cited by 12 | Viewed by 3302

Abstract

Background: Gastric adenocarcinoma (GA), one of the most common gastrointestinal cancers worldwide, is often accompanied by cancer cachexia in the advanced stage owing to malnutrition and cancer-related symptoms. Although resection is the most effective curative procedure for GA patients, it may cause perioperative [...] Read more.

Background: Gastric adenocarcinoma (GA), one of the most common gastrointestinal cancers worldwide, is often accompanied by cancer cachexia in the advanced stage owing to malnutrition and cancer-related symptoms. Although resection is the most effective curative procedure for GA patients, it may cause perioperative fatigue, worsening the extent of cancer cachexia. Although the relationship between cytokines and cancer fatigue has been evaluated, it is unclear which cytokines are associated with fatigue in GA patients. Therefore, this study aimed to investigate whether the changes in cytokine levels were associated with the perioperative changes in fatigue amongst GA patients. Methods: We included GA patients undergoing gastric surgery in a single academic medical center between June 2017 and December 2018. Fatigue-related questionnaires, serum cytokine levels (interferon-gamma, interleukin (IL)-1, IL-2, IL-5, IL-6, IL-12 p70, tumor necrosis factor-alpha, and granulocyte-macrophage colony-stimulating factor), and biochemistry profiles (albumin, prealbumin, C-reactive protein, and white blood cell counts) were assessed at three time points (preoperative day 0 (POD 0), post-operative day 1 (POD 1), and postoperative day 7 (POD 7)). We used the Brief Fatigue Inventory-Taiwan Form to assess the extent of fatigue. The change in fatigue scores among the three time points, as an independent variable, was adjusted for clinicopathologic characteristics, malnutrition risk, and cancer stages. Results: A total of 34 patients were included for analysis, including 12 female and 22 male patients. The mean age was 68.9 years. The mean score for fatigue on POD 0, POD 1, and POD 7 was 1.7, 6.2, and 3.6, respectively, with significant differences among the three time points (P < 0.001). Among the cytokines, only IL-6 was significantly elevated from POD 0 to POD 1. In the regression model, the change in IL-6 levels between POD 0 and POD 1 (coefficients = 0.01 for every 1 pg/mL increment; 95% confidence interval: 0.01–0.02; P = 0.037) and high malnutrition risk (coefficients = 2.80; 95% confidence interval: 1.45–3.52; P = 0.041) were significantly associated with changes in fatigue scores. Conclusions: The perioperative changes in plasma IL-6 levels are positively associated with changes in the fatigue scores of GA patients undergoing gastric surgery. Targeting the IL-6 signaling cascade or new fatigue-targeting medications may attenuate perioperative fatigue, and further clinical studies should be designed to validate this hypothesis. Full article

(This article belongs to the Special Issue Surgical Management of Gastric Cancer)

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Review

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15 pages, 2223 KiB

Open AccessReview

The Predictive Value of Low Muscle Mass as Measured on CT Scans for Postoperative Complications and Mortality in Gastric Cancer Patients: A Systematic Review and Meta-Analysis

by Alicia S. Borggreve, Robin B. den Boer, Gijs I. van Boxel, Pim A. de Jong, Wouter B. Veldhuis, Elles Steenhagen, Richard van Hillegersberg and Jelle P. Ruurda

J. Clin. Med. 2020, 9(1), 199; https://doi.org/10.3390/jcm9010199 - 11 Jan 2020

Cited by 32 | Viewed by 3376

Abstract

Risk assessment is relevant to predict outcomes in patients with gastric cancer. This systematic review aimed to investigate the predictive value of low muscle mass for postoperative complications in gastric cancer patients. A systematic literature search was performed to identify all articles reporting [...] Read more.

Risk assessment is relevant to predict outcomes in patients with gastric cancer. This systematic review aimed to investigate the predictive value of low muscle mass for postoperative complications in gastric cancer patients. A systematic literature search was performed to identify all articles reporting on muscle mass as measured on computed tomography (CT) scans in patients with gastric cancer. After full text screening, 15 articles reporting on 4887 patients were included. Meta-analysis demonstrated that patients with low muscle mass had significantly higher odds of postoperative complications (odds ratio (OR): 2.09, 95% confidence interval (CI): 1.55–2.83) and severe postoperative complications (Clavien–Dindo grade ≥III, OR: 1.73, 95% CI: 1.14–2.63). Moreover, patients with low muscle mass had a significantly higher overall mortality (hazard ratio (HR): 1.81, 95% CI: 1.52–2.14) and disease-specific mortality (HR: 1.58, 95% CI: 1.36–1.84). In conclusion, assessment of muscle mass on CT scans is a potential relevant clinical tool for risk prediction in gastric cancer patients. Considering the heterogeneity in definitions applied for low muscle mass on CT scans in the included studies, a universal cutoff value of CT-based low muscle mass is required for more reliable conclusions. Full article

(This article belongs to the Special Issue Surgical Management of Gastric Cancer)

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18 pages, 866 KiB

Open AccessReview

Systematic Review of the Role of Biomarkers in Predicting Anastomotic Leakage Following Gastroesophageal Cancer Surgery

by Cornelis Maarten de Mooij, Martijn Maassen van den Brink, Audrey Merry, Thais Tweed and Jan Stoot

J. Clin. Med. 2019, 8(11), 2005; https://doi.org/10.3390/jcm8112005 - 17 Nov 2019

Cited by 22 | Viewed by 3432

Abstract

Anastomotic leakage (AL) following gastroesophageal cancer surgery remains a serious postoperative complication. This systematic review aims to provide an overview of investigated biomarkers for the early detection of AL following esophagectomy, esophagogastrectomy and gastrectomy. All published studies evaluating the diagnostic accuracy of biomarkers [...] Read more.

Anastomotic leakage (AL) following gastroesophageal cancer surgery remains a serious postoperative complication. This systematic review aims to provide an overview of investigated biomarkers for the early detection of AL following esophagectomy, esophagogastrectomy and gastrectomy. All published studies evaluating the diagnostic accuracy of biomarkers predicting AL following gastroesophageal resection for cancer were included. The Embase, Medline, Cochrane Library, PubMed and Web of Science databases were searched. Risk of bias and applicability were assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) 2 tool. Twenty-four studies evaluated biomarkers in the context of AL following gastroesophageal cancer surgery. Biomarkers were derived from the systemic circulation, mediastinal and peritoneal drains, urine and mediastinal microdialysis. The most commonly evaluated serum biomarkers were C-reactive protein and leucocytes. Both proved to be useful markers for excluding AL owing to its high specificity and negative predictive values. Amylase was the most commonly evaluated peritoneal drain biomarker and significantly elevated levels can predict AL in the early postoperative period. The associated area under the receiver operating characteristic (AUROC) curve values ranged from 0.482 to 0.994. Current biomarkers are poor predictors of AL after gastroesophageal cancer surgery owing to insufficient sensitivity and positive predictive value. Further research is needed to identify better diagnostic tools to predict AL. Full article

(This article belongs to the Special Issue Surgical Management of Gastric Cancer)

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11 pages, 536 KiB

Open AccessReview

Prophylactic Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for Gastric Cancer—A Systematic Review

by H. J. F. Brenkman, M. Päeva, R. van Hillegersberg, J. P. Ruurda and N. Haj Mohammad

J. Clin. Med. 2019, 8(10), 1685; https://doi.org/10.3390/jcm8101685 - 15 Oct 2019

Cited by 37 | Viewed by 3806

Abstract

Survival after potentially curative treatment of gastric cancer remains low, mostly due to peritoneal recurrence. This descriptive review gives an overview of available comparative studies concerning prophylactic hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with gastric cancer with neither clinically evident metastases nor positive [...] Read more.

Survival after potentially curative treatment of gastric cancer remains low, mostly due to peritoneal recurrence. This descriptive review gives an overview of available comparative studies concerning prophylactic hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with gastric cancer with neither clinically evident metastases nor positive peritoneal cytology who undergo potentially curative gastrectomy. After searching the PubMed, Embase, CDSR, CENTRAL and ASCO meeting library, a total of 11 studies were included comparing surgery plus prophylactic HIPEC versus surgery alone (SA): three randomised controlled trials and eight non-randomised comparative studies, involving 1145 patients. Risk of bias was high in most of the studies. Morbidity after prophylactic HIPEC was 17–60% compared to 25–43% after SA. Overall survival was 32–35 months after prophylactic HIPEC and 22–28 months after SA. The 5-year survival rates were 39–87% after prophylactic HIPEC and 17–61% after SA, which was statistically significant in three studies. Peritoneal recurrence occurred in 7–27% in the HIPEC group, compared to 14–45% after SA. This review tends to demonstrate that prophylactic HIPEC for gastric cancer can be performed safely, may prevent peritoneal recurrence and may prolong survival. However, studies were heterogeneous and outdated, which emphasizes the need for well-designed trials conducted according to current standards. Full article

(This article belongs to the Special Issue Surgical Management of Gastric Cancer)

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