Journal of Gastric Cancer最新文献

The indications for endoscopic resection (ER) and the criteria for the curability of early gastric cancer (EGC) have been expanding. Among Korea, Japan, and Europe, Korea has the most strictly defined indication for ER, followed by Europe and Japan, whereas the curability criteria are relatively similar. Additional surgery is the standard treatment after noncurative resection; however, it is not frequently performed in older patients in clinical practice. Several risk-scoring systems have been developed to further stratify the risk of lymph node metastasis after noncurative resection, and they may help refine the indications for ER and curability assessment in older patients. Nevertheless, the current evidence remains insufficient to establish recommendations specific to this population. In older patients, most deaths are attributable to non-gastric cancer-related causes, regardless of the post-resection treatment strategy. Therefore, in addition to gastric cancer-specific mortality, non-gastric cancer-related mortality and quality of life should be considered. Endoscopic submucosal dissection (ESD) techniques continue to evolve. Traction methods and multibending endoscopes are useful for achieving safe and reliable ESD in selected cases. Although no intervention has been proven effective in reducing delayed bleeding after gastric ESD in randomized controlled trials, several closure methods have shown promising results in retrospective or phase II studies. Furthermore, novel image-enhanced endoscopies may help improve the technical success of gastric ESD. This review provides an evidence-based perspective that may guide optimal management of patients with EGC.

Purpose: Conditional relative survival (CRS) estimates the probability of survival after surgery compared with the general population. We assessed 5-year CRS up to 5 years after gastric resection.

Materials and methods: We analyzed 15,601 gastric cancer patients who underwent gastric resection between 1996 and 2018. Relative survival (RS) was defined as the ratio of observed survival in cancer patients to the expected survival in the general population. The 5-year CRS was the 5-year RS among patients who had survived a given number of years after surgery.

Results: Five-year CRS increased from 87.2% at one year to 95.4% at 5 years post-surgery. The most substantial increase was observed in stage III cancer, from 53.2% at one year to 85.2% at 5 years. If patients survived 5 years after surgery, their 5-year CRS was 95.4% for those under 40, 96.4% for those aged between 40 and 64, 92.7% for those aged between 65 and 79, and 99.4% for those 80 or older. Recent surgeries showed higher 5-year CRS at the time of surgery and improved CRS during early follow-up. Although there could be concerns about death from postoperative complications, patients in their 80s did not show lower RS than younger patients. Across operation types, total gastrectomy yielded lower 5-year CRS than distal gastrectomy from baseline through 5 years after surgery.

Conclusions: CRS improved over time, indicating that with careful candidate selection, surgery is safe, even for elderly patients. Additionally, patients who have undergone total gastrectomy may require nutritional support and long-term care.

Purpose: Despite a growing older adult population, few studies have compared the long-term outcomes of endoscopic submucosal dissection (ESD) with those of gastrectomy. This study examines long-term survival among older patients with early gastric cancer (EGC) treated with ESD versus gastrectomy.

Materials and methods: This retrospective cohort study used data from the Korea Clinical Data Utilization Network for Research Excellence. Patients aged ≥75 with stage IA gastric cancer (diagnosed 2014-2015) who underwent ESD or gastrectomy were followed for 5 years. All-cause and cause-specific mortality were assessed using Cox proportional hazard models and propensity score matching.

Results: Of the 442 patients (ESD, 269; gastrectomy, 173), the 5-year overall survival rates were 85.9% for ESD and 80.9% for gastrectomy (P=0.140). In patients aged ≥80, gastrectomy showed higher risks of total (adjusted hazard ratio [aHR], 3.29; 95% CI, 1.70-6.35) and gastric cancer-specific death (aHR, 7.18; 95% CI, 2.08-24.82) compared with ESD. In mucosa-confined lesions, gastrectomy also showed increased gastric cancer-specific mortality (aHR, 6.11; 95% CI, 1.93-19.35). The survival benefit of ESD was comparable to that of gastrectomy among patients aged 75-79 years and those with confined submucosal lesions.

Conclusions: ESD may offer better outcomes than gastrectomy among older patients with stage IA gastric cancer, particularly those aged ≥80 or with mucosa-confined lesions. ESD and gastrectomy may provide similar survival outcomes among patients aged 75-79 years and those with submucosa-confined lesions. These findings support the use of adaptive treatment strategies in older patients with EGC.

Purpose: Evidence for the effectiveness of intensive nutritional counseling in reducing weight loss among patients who have undergone gastrectomy for gastric cancer is limited. We evaluated the effectiveness of intensive nutritional counseling in reducing weight loss after subtotal gastrectomy.

Materials and methods: We conducted a prospective, parallel-assigned, double-blind randomized clinical trial to assess the effectiveness of intensive counseling (IC) compared with simplified counseling (SC) in reducing weight loss among patients who underwent subtotal gastrectomy for early gastric cancer. Patients were randomly assigned to either the IC or SC group between March 2021 and February 2023, with a final follow-up in September 2024. Patients in the IC group participated in an IC program delivered by specialized clinical dietitians. Patients in the SC group received only standard counselling sessions before discharge. The primary outcome was the percentage change in body weight from baseline to 12 months after subtotal gastrectomy.

Results: A total of 258 patients were enrolled and randomized (122 in the IC group and 136 in the SC group), with 249 patients (96.5%) completing the 18-month follow-up period. At 12 months postgastrectomy, no statistically significant difference was observed in the percentage change in body weight between the 2 groups (0.09 percentage points; 95% confidence interval, -1.43 to 1.60). Other nutritional factors also showed no significant differences between the groups.

Conclusions: Intensive nutritional counseling did not significantly reduce weight loss among gastric cancer patients after subtotal gastrectomy. Standard dietary counseling may be sufficient for dietary modification, although alternative approaches may be necessary.

Trial registration: ClinicalTrials.gov Identifier: NCT04798820.

Purpose: Claudin 18.2 (CLDN18.2) and fibroblast growth factor receptor 2b (FGFR2b) have recently emerged as promising therapeutic targets for advanced gastric cancer (GC). Before integrating CLDN18.2 and FGFR2b into routine practice, for optimal treatment planning, it is important to consider whether there exists an overlap between these biomarkers.

Materials and methods: We evaluated CLDN18.2 expression in many patients with GC (n=1,538) using tissue microarrays that had been previously used to evaluate FGFR2b overexpression. We investigated the overlap between CLDN18.2 and FGFR2b expression and evaluated the clinicopathological features and prognostic implications of CLDN18.2 expression.

Results: The CLDN18.2 positivity rates at 50% and 75% cutoffs were 34.7% and 24.4%, respectively. Heterogeneous expression was identified in 335 (23.5%) of 1426 cases with multiple tissue microarray cores. FGFR2b positivity at >0% cutoff was identified in 47 (3.1%) patients with more marked intratumoral heterogeneity than that observed with CLDN18.2. CLDN18.2 positivity (59.6%) in FGFR2b-positive GCs was significantly higher than that (33.9%) in FGFR2b-negative GCs (P<0.001). Concurrent FGFR2b- and CLDN18.2-positive GCs accounted for 1.8% of all patients, and FGFR2b-positive tumor cells were also positive for CLDN18.2 in approximately 75% of these cases. CLDN18.2 positivity was associated with poorly differentiated histology (P<0.001) and advanced pT and pN stages (P<0.03), but not with overall survival.

Conclusions: CLDN18.2 and FGFR2b were significantly associated with each other, suggesting a considerable overlap. This finding may have important clinical implications on the optimal treatment strategy for CLDN18.2-positive GC.

Purpose: Postoperative leakage is a critical complication of laparoscopic gastrectomy for gastric cancer. Predicting leakage during surgery can enhance patient outcomes by enabling a timely intervention. This study aimed to develop and validate deep learning models for predicting leakage using laparoscopic images of the anastomosis sites.

Materials and methods: We analyzed 10,256 laparoscopic images from 2,035 patients who underwent gastrectomy for gastric cancer at three institutions. Six datasets (EXP1 to EXP6) were created based on variations in image quality and analytical methods. Six deep learning architectures, ResNet18, ResNet34, ResNet50, EfficientNet_V2_L, Inception_V3, and DenseNet121, were employed for training. Deep learning models were trained to classify images into normal or leakage categories at the duodenal stump (DS) and esophagojejunal (EJ) anastomoses. Model performance was evaluated using F1 scores, recall, and Grad-CAM visualization.

Results: Leakage was identified in 1.3% and 4.3% of the patients with DS and EJ, respectively. Among the six datasets, EXP1, which used one image per patient and applied augmentation, exhibited the best performance. ResNet18 trained on EXP1 demonstrates the highest recall values, achieving 0.8474 for DS and 0.8000 for EJ, with F1 scores of 0.6357 and 0.6938, respectively. Grad-CAM revealed that both local and surrounding tissue features were critical for model prediction.

Conclusions: Deep learning could predict leakage during gastric cancer surgery. High-resolution imaging, single-image analysis, and data augmentation were pivotal for model performance. These findings lay the groundwork for clinical applications and future research on surgical image analysis.

Purpose: Many surgical methods have been developed for the optimal treatment of proximal early gastric cancer (GC); however, these approaches are still controversial. Proximal gastrectomy with direct esophagogastrostomy (EG), double-tract reconstruction (DTR), and double flap-technique (DFT) are considered function-preserving surgeries for proximal early GC rather than total gastrectomy (TG). We conducted a systematic review and network meta-analysis comparing EG, DTR, DFT, and TG to determine the surgical strategy for proximal GC.

Materials and methods: We systematically searched PubMed, Embase, Web of Science, and the Cochrane Library for studies that compared at least two of the following: EG, DTR, DFT, and TG. Then, we conducted a frequentist network meta-analysis to evaluate the clinical outcomes of 4 surgical methods.

Results: We included 38 studies and 3,497 patients. In this study, 15.4% of patients underwent EG, 39.2% DTR, 10.9% DFT, and 34.5% TG. Reflux esophagitis was statistically higher in EG than it was in DFT and DTR. Anastomotic stenosis was significantly lower in DTR than it was in EG. The 12-month postoperative hemoglobin level was the highest in DFT. DTR showed a significantly higher level than EG and TG. TG had the significantly lowest postoperative 12-month total protein level. For operative time, DFT showed the longest duration, and DTR showed a significantly longer duration than EG. For the first flatus time, DFT was the fastest, and DTR was significantly faster than TG. Regarding hospital length of stay, DFT was statistically shorter than the others.

Conclusions: DTR and DFT are more favorable methods than EG and TG, each with distinct advantages.

Trial registration: PROSPERO Identifier: CRD42024598575.

Purpose: The oncological safety of proximal gastrectomy (PG) for advanced Siewert II/III adenocarcinoma of the esophagogastric junction (AEG) remains controversial. We compared the long-term oncological outcomes of PG and total gastrectomy (TG) to refine the indications for PG.

Materials and methods: This dual-center retrospective study included 443 patients with pT2-4NanyM0 Siewert II/III AEG who underwent PG (n=192) or TG (n=251). Propensity score matching yielded 149 matched pairs. Perioperative outcomes, overall survival (OS), recurrence-free survival (RFS), and recurrence patterns were analyzed. Logistic regression analysis was used to assess risk factors for perigastric lymph nodes (PLN) recurrence after PG and key distal lymph nodes (KDLN) metastases after TG. The therapeutic index (TI) of KDLN metastases was calculated.

Results: Although survival rates were lower after PG, no significant differences were observed in OS (hazard ratio [HR],1.39; P=0.109) or RFS (HR, 1.30; P=0.212). PG was associated with more local recurrences (24.12% vs. 8.7%; P<0.001), especially PLN metastases (13.4% vs. 5.4%; P=0.023). In subgroup analyses, PG was associated with worse OS in pT4 patients (HR, 2.17; P=0.006) and worse RFS in pN3 patients (HR, 2.37; P=0.011). In patients who underwent TG, tumor size >6 cm (OR, 3.72) and pT4 (OR, 13.9) predicted KDLN metastasis. Patients with KDLN metastases had significantly worse OS (HR, 2.51; P<0.001).

Conclusions: TG is more suitable for patients with advanced Siewert II/III AEG with pT4, tumors >6 cm, or those with a high predicted risk of KDLN metastases. Accurate preoperative staging and intraoperative reassessment are essential for safe PG selection.

Trial registration: Chinese Clinical Trial Registry Identifier: ChiCTR2500102562.