Optimal treatment for Siewert type Ⅱ and Ⅲ adenocarcinoma of the esophagogastric junction: A retrospective cohort study with long-term follow-up

AIM To determine the optimal treatment strategy for Siewert type Ⅱ and?Ⅲ?adenocarcinoma of the esophagogastric junction.METHODS We retrospectively reviewed the medical records of 83 patients with Siewert type?Ⅱ?and?Ⅲ?adenocarcinoma of the esophagogastric junction and calculated both an index of estimated benefit from lymph node dissection for each lymph node(LN) station and a lymph node ratio(LNR: ratio of number of positive lymph nodes to the total number of dissected lymph nodes). We used Cox proportional hazard models to clarify independent poor prognostic factors. The median duration of observation was 73 mo.RESULTS Indices of estimated benefit from LN dissection were as follows, in descending order: lymph nodes(LN) along the lesser curvature, 26.5; right paracardial LN, 22.8; left paracardial LN, 11.6; LN along the left gastric artery, 10.6. The 5-year overall survival(OS) rate was 58%. Cox regression analysis revealed that vigorous venous invasion(v2, v3)(HR = 5.99; 95%CI: 1.71-24.90) and LNR of > 0.16(HR = 4.29, 95%CI: 1.79-10.89) were independent poor prognostic factors for OS.CONCLUSION LN along the lesser curvature, right and left paracardial LN, and LN along the left gastric artery should be dissected in patients with Siewert type?Ⅱ?or?Ⅲ?adenoca rcinoma of the esophagogastric junction. Patients with vigorous venous invasion and LNR of > 0.16 should be treated with aggressive adjuvant chemotherapy to improve survival outcomes.

Trend in gastric cancer:35 years of surgical experience in Japan

AIM:To investigate the trend in gastric cancer surgery in the context of rapid therapeutic advancement in Japan and East Asia.METHODS:A retrospective analysis was performed on 4163 patients who underwent gastric resection for gastric cancer with histological confirmation between 1971 and 2007 at the surgical unit in Kitasato University Hospital,to determine the trend in gastric cancer requiring surgery.RESULTS:Gastric cancer requiring surgical resection increased in our hospital,but the incidence adjusted for population was constant during the observed pe-riod.Interestingly,the ratio of diffuse type/intestinal type gastric cancer was unexpectedly unchanged,and that of advanced/early gastric cancer(EGC)was,however,markedly reduced,while the actual incidence of potentially curative advanced gastric cancer tended to decrease.The incidence of EGC requiring surgery tended to increase as a whole,which is consistent with increased prevalence of endoscopic surveillance.As a result,overall survival and mortality of gastric cancer requiring gastric resection has recently markedly improved.CONCLUSION:In Japan,planned interventions may improve surgical gastric cancer mortality,but an unexpected trend of persistent existence of intestinal type cancer suggests the need for more robust medical intervention.

Macroscopic appearance of TypeⅣand giant Type Ⅲ is a high risk for a poor prognosis in pathological stage Ⅱ/Ⅲ advanced gastric cancer with postoperative adjuvant chemotherapy

AIM To evaluate whether a high risk macroscopic appearance(Type Ⅳ and giant Type Ⅲ) is associated with a dismal prognosis after curative surgery, because its prognostic relevance remains elusive in pathological stage Ⅱ/Ⅲ(p Stage Ⅱ/Ⅲ) gastric cancer.METHODS One hundred and seventy-two advanced gastric cancer(defined as pT2 or beyond) patients with p Stage Ⅱ/Ⅲ who underwent curative surgery plus adjuvant S1 chemotherapy were evaluated, and the prognostic relevance of a high-risk macroscopic appearance was examined. RESULTS Advanced gastric cancers with a high-risk macroscopic appearance were retrospectively identified by preoperative recorded images. A high-risk macroscopic appearance showed a significantly worse relapse free survival(RFS)(35.7%) and overall survival(OS)(34%) than an average risk appearance(P = 0.0003 and P < 0.0001, respectively). A high-risk macroscopic appearance was significantly associated with the 13^(th) Japanese Gastric Cancer Association(JGCA) pT(P = 0.01), but not with the 13^(th) JGCA pN. On univariate analysis for RFS and OS, prognostic factors included 13^(th) JGCA p Stage(P < 0.0001)and other clinicopathological factors including macroscopic appearance. A multivariate Cox proportional hazards model for univariate prognostic factors identified highrisk macroscopic appearance(P = 0.036, HR = 2.29 for RFS and P = 0.021, HR = 2.74 for OS) as an independent prognostic indicator. CONCLUSION A high-risk macroscopic appearance was associated with a poor prognosis, and it could be a prognostic factor independent of 13^(th) JGCA stage in p Stage Ⅱ/Ⅲ advanced gastric cancer.

Newly emerging standard chemotherapies for gastric cancer and clinical potential in elderly patients

With the increase in average life expectancy,the rate of occurrence of gastric cancer in elderly patients is also rising.While many clinical trials have been conducted to examine the effect of chemotherapy treatment on gastric cancer,age limits for eligible subjects have prevented the establishment of standards for chemotherapy in elderly patients with gastric cancer.As of March 2009,evidence-based standard chemotherapy regimens were established.In the Western world,debates centered on the ECF(Epirubicin/cisplatin/5FU) or DCF(Docetaxel/cisplatin/5-FU) regimens based on the phase □ randomized controlled trial at the Royal Marsden Hospital(RMH) or the V325 study,respectively.The JCOG9912 and SPIRITS trials emerged from Japan indicating attractive regimens that include S-1 for advanced gastric cancer patients.Using these active anticancer drugs,the trials that studied the eff icacy of adjuvant therapies or surgical approaches,such as the Int-116/MAGIC/ACTS-GC trials,have actually succeeded in demonstrating the benefits of adjuvant therapies in gastric cancer patients.For cases of gastric cancer in elderly patients,treatment policies should consider these studies while analyzing not only the therapeutic effects but also drug toxicity,individual general health conditions,and social factors to select treatments that emphasize quality of life.