Prognostic nutritional index is an independent prognostic factor for gastric cancer patients with peritoneal dissemination

Objective： The predictive and prognostic role of prognostic nutritional index（PNI） in gastric cancer patients with peritoneal dissemination remains unclear. This study aims to explore the role of the PNI in predicting outcomes of gastric cancer patients with peritoneal dissemination.Methods： A total of 660 patients diagnosed with gastric adenocarcinoma with peritoneal metastasis between January 2000 and April 2014 at Sun Yat-sen University Cancer Center and the Sixth Affiliated Hospital of Sun Yatsen University were retrospectively analyzed. The clinicopathologic characteristics and clinical outcomes of patients with peritoneal dissemination were analyzed.Results： Compared with PNI-high group, PNI-low group was correlated with advanced age（P=0.036）, worse performance status（P0.001）, higher frequency of ascites（P0.001） and higher frequency of multisite distant metastasis（P0.001）. Kaplan-Meier survival curves showed that PNI-high group had a significantly longer median overall survival than PNI-low group（13.13 vs. 9.03 months, P0.001）. Multivariate survival analysis revealed that Borrmann type IV（P=0.014）, presence of ascites（P=0.017） and lower PNI（P=0.041） were independent poor prognostic factors, and palliative surgery（P0.001） and first-line chemotherapy（P0.001） were good prognostic factors. For patients receiving palliative surgery, the postoperative morbidity rates in the PNI-low group and PNIhigh group were 9.1% and 9.9%, respectively（P=0.797）. The postoperative mortality rate was not significantly different between PNI-low and PNI-high groups（2.3% vs. 0.9%, P=0.362）.Conclusions： PNI is a useful and practical tool for evaluating the nutritional status of gastric cancer patients with peritoneal dissemination, and is an independent prognostic factor for these patients.

A nomogram to predict prognosis for gastric cancer with peritoneal dissemination

Objective： To identify independent prognostic factors to be included in a nomogram to predict the prognosis ofgastric cancer patients with peritoneal dissemination.Methods： This is a retrospective study on 684 patients with a histological diagnosis of gastric cancer withperitoneal dissemination from the Sun Yat-sen University Cancer Center as the development set, and 62 gastriccancer patients from the Sixth Affiliated Hospital of Sun Yat-sen University as the validation group. Chi-square testand Cox regression analysis were used to compare the clinicopathological variables and the prognosis of gastriccancer patients with peritoneal dissemination. The Harrell＇s concordance index （C-index） and calibration curvewere determined for comparisons of predictive ability of the nomogram.Results： Univariate and multivariate analyses showed that serum carcinoembryonic antigen （CEA） level（P=0.032）, ascites grading （P=0.008）, presence of extraperitoneal metastasis （P〈0.001）, seeding status （P=0.016） andperformance status （P=0.009） were independent prognostic factors for gastric cancer patients with peritonealdissemination in the development set. The nomogram model was constructed using these five factors. Internalvalidation showed that the C-index of the model was 0.641. For the external validation, the C-index of this modelwas 0.709.Conclusions： We developed and validated a nomogram to predict the prognosis for gastric cancer patients withperitoneal dissemination. This nomogram may play an important clinical role in guiding palliative therapy for thesetypes of patients, although it may need more data for optimization.

Analysis and external validation of a nomogram to predict peritoneal dissemination in gastric cancer

Objective:Peritoneal dissemination is difficult to diagnose by conventional imaging technologies.We aimed to construct a nomogram to predict peritoneal dissemination in gastric cancer(GC)patients.Methods:We retrospectively analyzed 1,112 GC patients in Sun Yat-sen University Cancer Center between2001 and 2010 as the development set and 474 patients from The Sixth Affiliated Hospital,Sun Yat-sen University between 2010 and 2016 as the validation set.The clinicopathological variables associated with gastric cancer with peritoneal dissemination(GCPD)were analyzed.We used logistic regression analysis to identify independent risk factors for peritoneal dissemination.Then,we constructed a nomogram for the prediction of GCPD and defined its predictive value with a receiver operating characteristic(ROC)curve.External validation was performed to validate the applicability of the nomogram.Results:In total,250 patients were histologically identified as having peritoneal dissemination.Logistic regression analysis demonstrated that age,sex,tumor location,tumor size,signet-ring cell carcinoma(SRCC),T stage,N stage and Borrmann classification IV(Borrmann IV)were independent risk factors for peritoneal dissemination.We constructed a nomogram consisting of these eight factors to predict GCPD and found an optimistic predictive capability,with a C-index of 0.791,an area under the curve(AUC)of 0.791,and a 95%confidence interval(95%CI)of 0.762-0.820.The results found in the external validation set were also promising.Conclusions:We constructed a highly sensitive nomogram that can assist clinicians in the early diagnosis of GCPD and serve as a reference for optimizing clinical management strategies.

Peritoneal dissemination of pancreatic cancer caused by endoscopic ultrasound-guided fine needle aspiration:A case report and literature review

BACKGROUND Endoscopic ultrasound-guided fine needle aspiration(EUS-FNA)is a biopsy technique widely used to diagnose pancreatic tumors because of its high sensitivity and specificity.Although needle-tract seeding caused by EUS-FNA has been recently reported,dissemination of pancreatic cancer cells is generally considered to be a rare complication that does not affect patient prognosis.However,the frequency of dissemination and needle-tract seeding appears to have been underestimated.We present a case of peritoneal dissemination of pancreatic cancer due to preoperative EUS-FNA.CASE SUMMARY An 81-year-old man was referred to the Department of Surgery of our hospital in Japan owing to the detection of a pancreatic mass on computed tomography during medical screening.Trans-gastric EUS-FNA revealed that the mass was an adenocarcinoma;hence laparoscopic distal pancreatectomy with lymphadenectomy was performed.No intraoperative peritoneal dissemination and liver metastasis were visually detected,and pelvic lavage cytology was negative for carcinoma cells.The postoperative surgical specimen was negative for carcinoma cells at the dissected margin and the cut end margin;however,pathological findings revealed adenocarcinoma cells on the peritoneal surface proximal to the needle puncture site,and the cells were suspected to be disseminated via EUSFNA.Hence,the patient received adjuvant therapy with S-1(tegafur,gimeracil,and oteracil potassium);however,computed tomography performed 5 mo after surgery revealed liver metastasis and cancerous peritonitis.The patient received palliative therapy and died 8 mo after the operation.CONCLUSION The indications of EUS-FNA should be carefully considered to avoid iatrogenic dissemination,especially for cancers in the pancreatic body or tail.

Foreign body granulomas mimic peritoneal dissemination caused by incarcerated femoral hernia perforation:A case report

BACKGROUND Foreign body granuloma(FBG)is a well-known type of granulomatous formation,and intraabdominal FBG(IFBG)is primarily caused by surgical residues.Multifocal IFBGs caused by gastrointestinal perforation is an extremely rare and interesting clinicopathological condition that resembles peritoneal dissemination.Here,we present a case of IFBGs mimicking peritoneal dissemination caused by bowel perforation and describe the value of intraoperative pathological examinations for rapid IFBG diagnosis.CASE SUMMARY An 86-year-old woman with an incarcerated femoral hernia was admitted to the hospital and underwent operation.During the operation,the incarcerated ileum was perforated during repair due to hemorrhage necrosis,and a small volume of enteric fluid leaked from the perforation.The incarcerated ileum was resected,and the femoral hernia was repaired without mesh.Four months later,a second operation was performed for an umbilical incisional hernia.During the second operation,multiple small,white nodules were observed throughout the abdominal cavity,resembling peritoneal dissemination.The results of peritoneal washing cytology in Douglas’pouch and the examination of frozen nodule sections were compatible with IFBG diagnosis,and incisional hernia repair was performed.CONCLUSION IFBGs can mimic malignancy.Intraoperative pathological examinations and operation history are valuable for the rapid diagnosis to avoid excessive treatments.

Molecular mechanism of peritoneal dissemination in gastric cancer

Peritoneal dissemination(PD)is the most common cause of metastasis in gastric cancer(GC).Because there are no standard treatments for PD,it is associated with a poor prognosis.Although clinicians have performed intraperitoneal chemotherapy for GC with PD,the outcome remains unsatisfactory.Therefore,the development of novel treatments and diagnostic tools for PD is expected to improve the prognosis of GC patients with PD.Notably,it is essential to elucidate the molecular mechanisms involved in the development of PD in GC.In this review,the molecular mechanisms of PD(three steps:detachment from the primary tumor,adaptation to the microenvironment of the peritoneal cavity,and attachment to peritoneal mesothelial cells)and new topics in GC are highlighted.

Treatment of leiomyomatosis peritonealis disseminata with goserelin acetate: A case report and review of the literature

BACKGROUND Leiomyomatosis peritonealis disseminata(LPD)is a rare condition characterized by multiple pelvic and abdominal nodules,which are composed of smoothmuscle cells.To date,no more than 200 cases have been reported.The diagnosis of LPD is difficult and there are no guidelines on the treatment of LPD.Currently,surgical excision is the mainstay.However,hormone blockade therapy can be an alternative choice.CASE SUMMARY A 33-year-old female patient with abdominal discomfort and palpable abdominal masses was admitted to our hospital.She had undergone four surgeries related to uterine leiomyoma in the past 8 years.Computed tomography revealed multiple nodules scattered within the abdominal wall and peritoneal cavity.Her symptoms and the result of the core-needle biopsy were consistent with LPD.The patient refused surgery and was then treated with tamoxifen,ulipristal acetate(a selective progesterone receptor modulator),and goserelin acetate(a gonadotropin-releasing hormone agonist).Both tamoxifen and ulipristal acetate were not effective in controlling the disease progression.However,the patient achieved an excellent response when goserelin acetate was attempted with relieved syndromes and obvious shrinkage of nodules.The largest nodule showed a 25%decrease in the sum of the longest diameters from pretreatment to posttreatment.Up to now,2 years have elapsed and the patient remains asymptomatic and there is no development of further nodules.CONCLUSION Goserelin acetate is effective for the management of LPD.The long-term use of goserelin acetate is thought to be safe and effective.Hormone blockade therapy can replace repeated surgical excision in recurrent patients.

Disseminated peritoneal leiomyomatosis with malignant transformation involving right ureter:A case report

BACKGROUND Disseminated peritoneal leiomyomatosis(DPL)with myxoid leiomyosarcoma is a rare variant of leiomysosarcoma,and hematuria as a presenting symptom has never been reported.Through this case report,we emphasize the investigation of the etiology,clinical presentation,diagnosis,treatment,and prognosis of DPL with malignant changes mimicking metastatic urinary tract cancer and to help develop further clinical management.CASE SUMMARY We describe a case of DPL with malignant transformation involving the right ureter after laparoscopic hysterectomy.An exploratory laparotomy was performed and all visible nodules were surgically removed.DPL with focal malignant transformation to myxoid leiomyosarcoma was confirmed based on pathology results.CONCLUSION Professionals who preoperatively diagnose DPL with malignant change to myxoid leiomyosarcoma involving the genitourinary tract should consider symptoms of abdominal pain,hematuria,and imaging of disseminated pelvic tumors in women,especially those with prior history of laparoscopic hysterectomy.Early complete removal of all tumors is the cornerstone to prevent DPL from malignant changes.

Depth of tumor invasion and tumor-occupied portions of stomach are predictive factors of intra-abdominal metastasis

Objective： Diagnostic laparoscopy is recommended for the pretherapeutic staging of gastric cancer to detect any unexpected or unconfirmed intra-abdominal metastasis. The aim of this study was to evaluate the role and indications of diagnostic laparoscopy in the detection of intra-abdominal metastasis. Methods： Standard diagnostic laparoscopy with peritoneal cytology examination was performed prospectively on patients who were clinically diagnosed with primary local advanced gastric cancer （CT≥2M0）. We calculated the rate of intra-abdominal metastases identified by diagnostic laparoscopy, and examined the relationship between peritoneal dissemination （P） and cytology results （CY）. Split-sample method was applied to find clinical risk factors for intra-abdominal metastasis. Multivariate logistic regression analysis and receiver-operator characteristic （ROC） analysis were performed in training set to find out risk factors ofintra-abdominal metastasis, and then validate it in testing set. Results： Out of 249 cM0 patients, 51 （20.5%） patients with intra-abdominal metastasis were identified by diagnostic laparoscopy, including 20 （8.0%） P1CY1, 17 （6.8%） POCY1 and 14 （5.6%） P1CY0 patients. In the training set, multivariate logistic regression analysis and ROC analysis showed that the depth of tumor invasion on computer tomography （CT） scan ≥21 mm and tumor-occupied 〉2 portions of stomach are predictive factors of metastasis. In the testing set, when diagnostic laparoscopy was performed on patients who had one or two of these risk factors, the sensitivity and positive predictive value for detecting intra-abdominal metastasis were 90.0% and 32.1%, respectively. Conclusions： According to our results, depth of tumor invasion and tumor-occupied portions of stomach are predictive factors ofintra-abdominal metastasis.