Laura Ruspi

Laparoscopic gastrectomy for gastric cancer: Current evidences

Nowadays, our understanding of gastric cancer has been improved. The major hope is to increase the survival rates of this aggressive, enigmatic and heterogeneous disease, especially in Western population. Over the past decades, conventional surgery has been the cornerstone of treatment for non metastatic gastric cancer patients. Adequate gastrectomy is recommended for at least T2-4a tumors, while T4b tumors require resection of involved structures. However, in the era of advanced technology, minimally invasive surgical approaches are in the top of the scientific interest. Notably, the laparoscopic approach for gastric cancer is a topic that remain controversial. In this review, we summarize the standard of care according to the current evidences and we provide the latest scientific information assessing safety and efficacy of laparoscopic gastrectomy for gastric cancer.

Peri-operative blood transfusion in gastric cancer surgery: prognostic or confounding factor?

BACKGROUND AND PURPOSE The relationship between peri-operative blood transfusions (PBTs) and poor prognosis in gastric cancer (GC) patients is still debated. The aim of this study is to examine the real prognostic impact of PBTs in comparison to well-known prognostic factors. METHODS We retrospectively analyzed a series of 224 patients who underwent surgery with curative intent for GC from January 1995 to December 2011. Among 224 patients, 46 (20%) required PBTs. RESULTS The overall 5-year survival was 77% in non-transfused patients and 65% in patients who received PBTs (p = 0.03). PBTs did not further stratify any recognized prognostic category (such as pT or pN according to the 7th edition of the TNM staging system). Multivariate analysis including all known prognostic variables (both cancer- and non-cancer-related) did not select PBTs as an independent prognostic factor. Only preoperative hemoglobin and albumin level, pT and operative time were significantly associated with the requirement for PBTs. CONCLUSIONS The study showed a worse prognosis for transfused patients, but PBTs seem a confounding factor more than a prognostic indicator, as they are obviously affected by other variables.

Lymph node staging in gastric cancer: new criteria, old problems

PURPOSE Our study aims to test the prognostic accuracy of the N parameter of the 7th TNM in a Western series of D1-gastrectomies for gastric cancer (GC). METHODS Retrospectively considering a series of 224 non-metastatic GC patients who underwent surgery with curative intent and limited lymphadenectomy, we analyzed 5-year overall survival (OS) related to pN status according to both TNM editions (pN6 and pN7) and to lymph node ratio (LNR; LNR0, 0%, LNR1, 1-19%; LNR2, > 20%). We stratified pN6- and pN7-related OS by LNR. RESULTS Both pN6 and pN7 were shown to significantly stratify different subsets of GC patients, but there was no significant difference between pN71 and pN72, nor between pN62 and pN63. A multivariate model specific for pN7 eliminated the N2 group, while the pN6 model maintained all 3 N groups with highly discriminating hazard ratios. LNR was able to further stratify one category of pN6 (N2) and two categories of pN7 (N1 and N2). CONCLUSIONS The 7th TNM edition for GC does not seem to be superior to the 6th edition in evaluating the prognostic relevance of lymph-nodal status: in particular, it does not allow an accurate stratification of OS in patients with less than 6 positive lymph nodes.

Seventh tumor-node-metastasis staging of gastric cancer: Five-year follow-up

Seventh tumor-node-metastasis (TNM) classification for gastric cancer, published in 2010, introduced changes in all of its three parameters with the aim to increase its accuracy in prognostication. The aim of this review is to analyze the efficacy of these changes and their implication in clinical practice. We reviewed relevant Literature concerning staging systems in gastric cancer from 2010 up to March 2016. Adenocarcinoma of the esophago-gastric junction still remains a debated entity, due to its peculiar anatomical and histological situation: further improvement in its staging are required. Concerning distant metastases, positive peritoneal cytology has been adopted as a criterion to define metastatic disease: however, its search in clinical practice is still far from being routinely performed, as staging laparoscopy has not yet reached wide diffusion. Regarding definition of T and N: in the era of multimodal treatment these parameters should more influence both staging and surgery. The changes about T-staging suggested some modifications in clinical practice. Differently, many controversies on lymph node staging are still ongoing, with the proposal of alternative classification systems in order to minimize the extent of lymphadenectomy. The next TNM classification should take into account all of these aspects to improve its accuracy and the comparability of prognosis in patients from both Eastern and Western world.

Updates on Surgical Management of Advanced Gastric Cancer: New Evidence and Trends. Insights from the First International Course on Upper Gastrointestinal Surgery—Varese (Italy), December 2, 2011

Between the Ninth International Gastric Cancer Congress (IGCC) in South-Korea (Seoul, 2011) and the Tenth IGCC in Italy (Verona, 2013), the Insubria University organized the First International Course on Upper Gastrointestinal Surgery (Varese, December 2, 2011), with the patronage of Italian Research Group for Gastric Cancer (IRGGC) and the International Gastric Cancer Association (IGCA). The Course was intended to be a comprehensive update and review on advanced gastric cancer (GC) staging and treatment from well-known international experts. Clinical, research, and educational aspects of the surgeon’s role in the era of stage-adapted therapy were discussed. As highlighted in the meeting, in this final document we summarize and thoroughly analyze (with references only for well-acquired randomized control trials) the new and old open problems in surgical management of advanced GC.

A “perfect” lymph node staging system requires a “perfect” surgery

Lymph node metastases are well known predictors of poor prognosis in gastric cancer patients after curative surgery.

Advantages of staging laparoscopy in gastric cancer: they are so obvious that they are not evident

1st Division of General Surgery, Department of Human Morphology & Surgical Sciences, Insubria University Varese-Como, Italy Department of General Surgery, Ioannina University Hospital, Centre for Biosystems & Genomic Network Medicine, Ioannina University, Ioannina, Greece *Author for correspondence: stefano.rausei@ospedale.varese.it Gastric cancer is the second most common cause of cancer death and it often presents in an advanced stage at the time of diagnosis. As treatment strategies are different for metastatic and locally advanced disease, the importance of an accurate preoperative staging is evident, especially in the era of tailored treatment. Although several improvements in radiologic imaging have occurred, extraserosal invasion, nodal involvement, peritoneal carcinomatosis and small liver metastases still are unexpected findings at the time of laparotomy. Abdominal ultrasound has a good sensitivity in detecting liver metastases with an accuracy around 53 and 76% [1], but its sensitivity significantly decreases (20%) for lesions 1 cm [2]. Finally, FDG-PET has a low resolution (4–5 mm), which limits its sensitivity in defining both nodal i nvolvement and primary tumor depth [4]. Staging laparoscopy is a minimally invasive surgical approach performed in order to evaluate the intra-abdominal involvement of disease and it is indicated in patients who have gastric cancer with no distant metastases detected on optimal pre-operative imaging. This technique enables the de visu appreciation of intraabdominal organs on their surface areas. What is more, it facilitates the bioptic harvesting, it allows free peritoneal fluid withdrawal for cytologic examination (mandatory according to the new TNM edition [5]) and it enables the use of laparoscopic ultrasounds, which has been shown to potentially further increase the accuracy of T and M parameter definition [6–9]. Technically, this minimally invasive technique is carried out during general anesthesia. It can also be performed immediately before gastrectomy. The patient position is supine (we usually perform a peri-umbilical open technique approach to the abdominal cavity). A 10‐mm trocar is introduced under the umbilical scar in order to access the abdominal cavity. Additionally, a 30° scope is introduced in order to get a clear and wide de visu assessment of the supramesocolic region. The ‘inverted TNM mode’ should be applied when this surgical procedure is performed [10]. In particular, any potential ascitic fluid must be totally harvested for immediate “...in the era of tailored treatment, the basis of optimized therapies is the correct evaluation of tumor spread and exact staging...”

Prognostic Indicators in Stage IV Surgically Treated Gastric Cancer Patients: A Retrospective Multi-Institutional Study

Introduction: The role of gastric resection in treating metastatic gastric adenocarcinoma is controversial. In the present study, we reviewed the short- and long-term outcomes of stage IV patients undergoing surgery. Methods: A retrospective review was conducted that assessed patients undergoing elective surgery for incurable gastric carcinoma. Short- and long-term results were evaluated. Results: A total of 122 stage IV gastric cancer patients were assessed. Postoperative mortality was 5.7%, and the overall rate of complications was 35.2%. The overall survival rate at 1 and 3 years was 58 and 19% respectively; the median survival was 14 months. Improved survival was observed for the factors age less than 60 years (p = 0.015), site of metastases (p = 0.022), extended lymph node dissection (p = 0.044), absence of residual disease after surgery (p = 0.001), and administration of adjuvant chemotherapy (p = 0.016). Multivariate analysis showed that residual disease and adjuvant chemotherapy were independent prognostic factors. Conclusions: The results of this study suggest that surgery combined with systemic chemotherapy in selected patients with stage IV gastric cancer can improve survival.

N staging system: tumor-node-metastasis and future perspectives

The correct staging of disease, with an exact definition of the extent of cancer at the diagnosis, is crucial in the planning of a specific treatment and in the assessment of real chances of cure. Cancer staging systems are expected to be accurate in the description of the severity of a patients tumor on the basis of the extent of the primary neoplasm and of its spread, thus giving clinician tools to estimate prognosis and providing objective parameters to compare groups of patients in clinical studies. This last point is of wide importance in evaluating successful treatment strategies in oncology, and this is one of the issues that contributed to the development of stage-adapted therapies.

Neoadjuvant chemotherapy in locally advanced gastric cancer: what to avoid. Preliminary analysis of a consecutive series of patients

Aims and background The role of neoadjuvant (NAD) chemotherapy (CHT) in patients with locally advanced gastric cancer (LAGC) is validated. However, some important limitations emerged from the literature, including patient selection, quality of surgery, and pathologic response evaluation. Neoadjuvant CHT for LAGC has been evaluated with a focus on safety and efficacy of the preoperative approach in terms of patient compliance, surgical outcomes, and pathologic response. Methods and Study Design Ninety-one patients with gastric adenocarcinoma were prospectively observed. All patients received computed tomography scan and laparoscopy staging. Ten patients with LAGC (including 2 with LAGC suspected for cM+/lapM+) had been recruited in the preoperative ECF/EOX CHT protocol and were compared with 61 patients who underwent surgery alone. Results The overall compliance for the preoperative CHT group was higher than compliance for adjuvant CHT observed in both the NAD CHT group and the surgery alone group. There were 2 treatment shifts to FOLFOX in the preoperative regimen. In the preoperative CHT group, D2-gastrectomy was possible only in 6/10 of cases, with a R0 resection rate of 67% (versus 64% in the LAGC patients treated by surgery alone). The postoperative mortality and morbidity were 0% and 17% in the NAD CHT group versus 2% and 26% in the surgery alone group. The overall pathologic response rate after NAD CHT was 83% (5/6). Conclusions Staging and CHT management problems can negatively affect patient outcomes. In the LAGC setting, when well applied, NAD CHT could be considered a valuable treatment option.