Journal of Gastric Cancer最新文献

Purpose: Radical gastrectomy with lymphadenectomy remains the standard treatment for gastric cancer. Minimally invasive gastrectomy, particularly the reduced-port robotic gastrectomy (REPROG), has gained attention because of its precision and reduced invasiveness. This study aimed to establish a nationwide REPROG database in Korea and to evaluate its clinical outcomes.

Materials and methods: All patients who underwent REPROG between February 2014 and December 2023 were analyzed. A comprehensive analysis of these patients, including perioperative outcomes, was conducted. To compare outcomes, a control group was selected from the 2019 Korea Nationwide Gastrectomy Database, focusing on patients receiving multiport conventional laparoscopic gastrectomy (CLG). A 1:2 propensity score matching was performed based on patient, tumor, and surgical characteristics. Perioperative outcomes, including the length of hospital stay, were compared between the matched cohorts.

Results: A total of 1,071 patients who underwent REPROG were collected, of which 1,060 were included after exclusion and compared with CLG cases from a nationwide database. REPROG demonstrated a significant reduction in hospital stay, with a mean duration of 6.1 days compared with 7.8 days for the CLG (P<0.001). The incidence of major complications was similar between the 2 groups (1.9% vs. 2.4%, P=0.493). The conversion rate for REPROG was 0.19%. The annual number of patients receiving REPROG steadily increased, reaching 267 patients (24.9%) by 2023.

Conclusions: Patients undergoing REPROG had a shorter hospital stay and a low conversion rate, indicating its potential as a treatment option for gastric cancer when performed by highly experienced surgeons.

Purpose: Immunotherapy combined with chemotherapy is the standard palliative treatment for gastric cancer. However, peritoneal metastases are often resistant to immunotherapy, underscoring the need to better understand the tumor immune microenvironment (TIME). In this study, we aimed to comprehensively analyze the TIME in peritoneal metastases of gastric cancer.

Materials and methods: Paired single-cell suspensions from malignant ascites and peripheral blood mononuclear cells (PBMCs) were obtained from 27 patients with gastric cancer for multicolor fluorescence-activated cell sorting (FACS) analysis. Cell-free fluids from malignant ascites and plasma of 15 patients with gastric cancer, along with benign ascites from 15 patients with liver cirrhosis, were analyzed using multiplex enzyme-linked immunosorbent assay (ELISA). Paired samples of primary gastric tumors and metastatic peritoneal tumors from 12 patients were evaluated using multiplex immunohistochemistry (IHC).

Results: FACS analysis revealed that T cells in malignant ascites expressed higher levels of immune checkpoint receptors (programmed death-1, T-cell immunoglobulin and mucin-domain containing-3, T-cell immunoglobulin and ITIM domain, lymphocyte activation gene-3, and cytotoxic T-lymphocyte antigen 4), and that CD8⁺ T cells exhibited terminal exhaustion (Eomes^highT-bet^low). Multiplex ELISA showed that soluble immunosuppressive factors (matrix metalloproteinase [MMP]-1, MMP-2, MMP-7, transforming growth factor-beta 1, hepatocyte growth factor, E-cadherin, vascular endothelial growth factor, and angiopoietin-2) were elevated in malignant ascites. Multiplex IHC showed lower CD4⁺ and CD8⁺ T cell densities in metastatic peritoneal tumors, which predominantly exhibited immunosuppressive TIME subtypes (immune-desert and intrinsic induction).

Conclusions: Our results revealed distinct peritoneal immunosuppressive TIMEs in patients with gastric cancer with peritoneal metastasis.

Purpose: This trial (KLASS-12) compares the efficacy and safety of reduced-port laparoscopic gastrectomy (RPLG) versus conventional 5-port laparoscopic gastrectomy (CPLG) for early gastric cancer (EGC).

Materials and methods: This multicenter, open-label, randomized controlled trial enrolled patients diagnosed with gastric adenocarcinoma (T1N0M0) at 15 university hospitals in Korea. Participants underwent RPLG or CPLG with at least D1+ lymph node dissection. The primary aim of this study was to verify the non-inferiority of RPLG to CPLG in terms of postoperative 30-day complications.

Results: From May 2022 to October 2023, 348 patients were randomly assigned to the RPLG and CPLG groups, with 174 patients in each group. After applying the exclusion criteria, 164 and 166 patients from the RPLG and CPLG groups, respectively, were analyzed. Complication rates were 10.4% and 9.2% for the RPLG and CPLG groups, in the intention-to-treat (ITT) population, and 10.4% vs. 7.2% in the per-protocol (PP) population. The risk difference was 0.012 (95% confidence interval [CI], -0.051 to 0.075) in the ITT population and 0.031 (95% CI, -0.030 to 0.093) in the PP population. These findings verified the non-inferiority of RPLG to CPLG, with a 10% margin. Additionally, the pain score on postoperative day 5 was significantly lower in the RPLG group (1.6% vs. 1.8%; P=0.028). The 2 groups showed no significant differences in the lymph node yield, conversion rate, or length of hospital stay. RPLG was not an independent risk factor for complications.

Conclusions: RPLG is a feasible and safe alternative for patients with EGC, and its short-term outcomes are not inferior to those of CPLG.

Trial registration: Clinical Research Information Service Identifier: KCT0006935.

Purpose: Decisions regarding gastric cancer treatment affect patient outcomes and quality of life (QOL); nonetheless, factors influencing patient preferences remain unclear. This study investigated the preferences for the extent of gastrectomy, minimally invasive surgery, and adjuvant therapy while identifying the key determinants.

Materials and methods: A cross-sectional survey of 240 respondents, including patients with gastric cancer and the general population, assessed their preferences for the extent of gastrectomy, surgical modality, adjuvant therapy, palliative systemic therapy, and endoscopic therapy. Correlations between demographic variables and treatment choices were statistically analyzed.

Results: Patients prioritized expert recommendations for determining the extent of gastrectomy for proximal gastric cancer and selecting the surgical modality, with recurrence risk and surgical complications being the primary considerations. In terms of adjuvant therapy, a 12-month oral regimen was preferred over a 6-month oral plus injection regimen, with survival benefit being the most valued factor. Conversely, QOL was a primary concern in palliative therapy. With respect to incomplete endoscopic submucosal dissection, electrocauterization was the preferred approach, followed by surgical resection; local recurrence risk was assigned with the highest priority, followed by concerns regarding lymph node metastasis. Men and individuals living alone had a lower risk of recurrence and lymph node metastasis. Patients undergoing gastric cancer treatment preferred shorter procedures, whereas medical personnel emphasized surgical safety and efficiency.

Conclusions: Demographic and clinical factors significantly influence patient preferences. Understanding these preferences is essential for shared decision-making and personalized oncological care.

Purpose: Minimally invasive surgery for gastric cancer has become popular owing to its proven technical feasibility and oncological safety compared with conventional open gastrectomy. Although intracorporeal (IC) esophagojejunostomy (EJ) is commonly performed, a standardized method remains undetermined. This study compared short-term outcomes of IC EJ using circular versus linear stapling techniques.

Materials and methods: We retrospectively assessed 586 patients with gastric cancer who underwent minimally invasive proximal or total gastrectomy between 2010 and 2021. Finally, 158 and 392 patients who underwent IC EJ anastomosis with circular and linear stapling, respectively, were included in this study. Surgical outcomes and complication rates were compared between the 2 groups after adjusting for confounding variables using inverse probability of treatment weighting.

Results: The total number of complications did not differ between the 2 groups (P=0.138). However, major complications occurred more frequently in the circular stapling group than in the linear stapling group (15.2% vs. 7.4%, P=0.041). There was no significant intergroup difference in EJ-related anastomotic leakage (1.9% vs. 2.1%, P=0.916). The incidence of anastomotic stenosis was lower in the linear stapling group than in the circular stapling group (10.8% vs. 0.5%, P<0.001). Additionally, the pain score on postoperative day 1 was lower in the linear stapling group (3.48 vs. 3.09, P<0.001).

Conclusions: Both linear and circular stapling can be used in IC EJ. However, linear stapling is a more suitable option because it has several advantages, including a reduced incidence of EJ-related stenosis and less postoperative pain attributable to differences in the length of the incision.

This corrects the article on p. 418 in vol. 21, PMID: 35079443.

Purpose: Although immune checkpoint inhibitors (ICIs) and chemotherapy combinations have been approved for the treatment of gastric and gastroesophageal junction cancer (GC/GEJC), whether immunochemotherapy (ICT) offers advantages over the simple addition of individual monotherapies remains unclear. This study aimed to investigate whether ICT has a synergistic effect in patients with advanced GC/GEJC.

Materials and methods: Reconstructed individual patient data were electronically extracted from the Kaplan-Meier curves of 3 randomized controlled trials comparing pembrolizumab (KEYNOTE-061, KEYNOTE-062, and KEYNOTE-859). The observed progression-free survival (PFS) curve for each monotherapy was used to estimate the simulated PFS curve expected under an independent drug action model. If the observed curve demonstrated significantly better PFS than the simulated curve, combined ICI and chemotherapy was determined to have a synergistic effect, implying a superior outcome compared to adding-component monotherapy.

Results: In patients with programmed cell death ligand 1 combined positive scores of ≥1 (n=2,194), the 1-year and median PFS of the observed and simulated curves were 28.0% vs. 27.9% and 6.89 months vs. 6.88 months, respectively. The one-sample log-rank test revealed no significant differences between the observed and simulated curves (P=0.107).

Conclusions: The observed PFS with ICT was comparable to the predicted PFS based on the data for each monotherapy. Our findings do not provide direct evidence of synergistic effects, but they suggest that combining ICI and chemotherapy does not compromise efficacy. These results may support the continued clinical use of ICT in patients with advanced GC/GEJC.

Purpose: This study aimed to identify the current perioperative management practices for gastric cancer surgery in South Korea and develop a consensus-driven Enhanced Recovery After Surgery (ERAS) protocol for a multicenter randomized controlled trial (RCT).

Materials and methods: A survey was conducted with 20 principal investigators, comprising one gastric surgeon and one anesthesiologist each, from 10 tertiary hospitals in South Korea who participated in a planned multicenter RCT. The survey included 41 questions regarding ERAS implementation and department-specific perioperative management practices. The responses were analyzed using descriptive statistics, and the findings were used to develop a consensus-driven ERAS protocol.

Results: A total of 20 participants completed the survey. Most respondents estimated the overall compliance rate with ERAS protocols for gastric cancer surgery to be 30%-50%. A major barrier to ERAS implementation is limited personnel resources. The survey revealed significant variability in perioperative practices-particularly in postoperative oral feeding protocols and expected discharge dates-across institutions. Most institutions practice water fasting from midnight before surgery, and the adoption rate of multimodal opioid-sparing analgesia is low. Based on these findings, an ERAS protocol was established through collaborative discussions to shorten perioperative fasting periods and implement multimodal opioid-sparing analgesia.

Conclusions: This study revealed significant variability in the perioperative management of gastric cancer surgery in South Korea. A consensus-driven ERAS protocol was established to standardize care and promote functional recovery. Its feasibility and effectiveness should be evaluated in an upcoming multicenter RCT.