Kan Xue

Background: Laparoscopic gastrectomy (LG) for gastric cancer has rapidly developed and become more popular in recent decades. Additional high-quality randomized controlled trial (RCT) studies comparing LG versus open gastrectomy (OG) for gastric cancer (GC) have been published in recent years. An updated systematic review is warranted. The aim of our meta-analysis was to comprehensively evaluate the short- and long-term outcomes of LG versus OG for GC. Materials and methods: The PubMed, Embase, Web of Science, and Cochrane Center Register of Controlled Trials databases were comprehensively searched to identify RCTs comparing LG versus OG for GC published between January 1994 and December 7, 2021. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Cochrane Collaboration and the Quality of Reporting of Meta-analyses (QUORUM) guidelines. All RCTs comparing the short- and long-term outcomes of LG with those of OG were included. A random effects model was adopted with significant heterogeneity (I² > 50%), while a fixed effects model was employed in all other cases (I² ≤ 50%). Results: A total of 26 RCTs with 8301 patients were included in this meta-analysis. The results indicated that the intraoperative complication rate was comparable between the LG group and the OG group (OR=1.14, 95% CI [0.76, 1.70], I²=0%, p=0.53). The LG group had fewer postoperative complications than the OG group (OR=0.65, 95% CI [0.57, 0.74], I²=26%, pI²=10%, p=0.10; OR=1.11, 95% CI [0.59, 2.09], I²=0%, p=0.74, respectively). The number of lymph nodes retrieved by the LG group was less than that of the OG group (MD=−1.51, 95% CI [−2.29, −0.74], I²=0%, pI²=23%, p=0.003), but the distal resection margin distance in the two groups was comparable (MD=−0.21, 95% CI [−0.47, 0.04], I²=0%, p=0.10). The time to first ambulation was shorter in the LG group than in the OG group (MD=−0.14, 95% CI [−.26, −0.01], I²=40%, p=0.03). The time to first flatus was also shorter in the LG group than in the OG group (MD=−0.15, 95% CI [−0.23, −0.07], I²=4%, p=0.0001). However, the first time on a liquid diet was comparable between the two groups (MD=−0.30, 95% CI [−0.64, 0.04], I²=88%, p=0.09). Furthermore, the postoperative length of stay was shorter in the LG group than in the OG group (MD=−1.26, 95% CI [−1.99, −0.53], I²=90%, p=0.0007). The 5-year overall survival (OS) was comparable between the two groups (HR=0.97, 95% CI [0.80, 1.17], I²=0%, p=0.73), and the 5-year disease-free survival (DFS) was also similar between the LG group and OG group (HR=1.08, 95% CI [0.77, 1.52], I²=0%, p=0.64). Conclusion: LG is a technically safe and feasible alternative to OG with the advantages of a fewer postoperative complication rate, faster recovery of gastrointestinal function, and greater cosmetic benefit for patients with GC. Meanwhile, LG has comparable long-term outcomes to OG for GC.

Gastric cancer is one of the most common malignant tumors worldwide. With the rapid aging of global population, the number of elderly patients with local advanced gastric cancer is increasing. Surgery is the essential treatment for local advanced gastric cancer. However, elderly patients are at high risk of postoperative complications due to reduced functional reserve and increased comorbidities. Laparoscopic gastrectomy may be a promising surgery approach for elderly patients but its benefits remain controversial. We therefore proposed this randomized trial to evaluate the safety and efficacy of laparoscopic versus open gastrectomy for local advanced gastric cancer in patients aged 70 and above. The current study has a randomized, parallel controlled, single-center, open-label, superiority design with two arms. A sample of 180 local advanced gastric cancer patients aged 70 and above will be recruited in Peking University Cancer Hospital and Institute. Participants will be randomized to either receive open or laparoscopic gastrectomy. The primary outcome is surgical safety, including complication rate, reoperation rate, readmission rate, and mortality rate within 30 days after surgery. The secondary endpoints include postoperative rehabilitation status, one-year postoperative life quality, three-year overall and disease-free survival. Assessments will take place at baseline (before random assignment), at 30 days, one-year, and three-year after the surgery. The study has been approved by an ethical review board. We hypothesized that laparoscopic gastrectomy is superior to open gastrectomy in terms of perioperative safety for local advanced gastric cancer patients aged 70 and above. If this hypothesis is statistically proved, the rational introduction of minimally invasive surgery technique in traditional gastrectomy can help improve the surgical safety for elderly patients, reduce patient financial burden, shorten hospital stay, and improve hospital beds turnover rate. Our research data will also provide high quality clinical evidence and data support for the conduction of multicenter phase III clinical trials. The study has been prospectively registered in ClinicalTrial.gov ( NCT03564834 ).

Introduction Current guidelines recommend open gastrectomy with D2 lymph node dissection and adjuvant chemotherapy as the standard treatment for advanced gastric cancer. However, the prognosis is not satisfactory. Perioperative chemotherapy has been proposed to improve survival. Although still in debate, the efficacy of laparoscopic distal gastrectomy (LDG) in patients with advanced gastric cancer has been demonstrated in a few trials. Therefore, LDG after neoadjuvant chemotherapy can be a candidate for future standard treatment on advanced distal gastric cancer. We propose a randomised phase II trial to compare LDG and open distal gastrectomy (ODG) after neoadjuvant chemotherapy for advanced gastric cancer. Methods and analysis To test the efficacy and safety, a randomised, open-label, single-centre, phase II trial was designed to evaluate the non-inferiority of LDG compared with ODG after neoadjuvant chemotherapy, with 3-year recurrence-free survival as the primary endpoint. The chosen critical value of a non-inferiority margin was an increase of Ethics and dissemination This study was approved by the Peking University Cancer Hospital Ethics Committee. The results will be submitted for publication in peer-reviewed journals. Trial registration number NCT02404753; Pre-results.

This study aims to evaluate the new ypTNM staging system in Chinese gastric cancer patients.

To investigate the current status of diagnosis and treatment of early gastric cancer in China, based on the nationwide survey by China Gastrointestinal Cancer Surgery Union. The union sent questionnaires on basic diagnosis and treatment data of gastric and colorectal cancer to all the centers of the union. Different centers collected and summarized their data by year and sent back the questionnaires to the e-mail of theunion(gi_union@foxmail.com) for summary. From 2014 to 2016, the union collected 285 questionnaires from 85 centers all over China. In these 3 years, a total of 88 340 cases of gastric cancer were summarized and there were 17 187 cases of early gastric cancer (part of the data was not available in some centers). The proportion of early gastric cancer varied from 19.5%(5711/29290) in 2014 to 19.0%(6081/32050) in 2015 and 20.0%(5395/27000) in 2016. Significant difference was found among them (χ2=9.553, P=0.008). Significant differences existed not only in the proportion of early gastric cancer between the south (20.9%, 7618/ 36518) and the north (18.5%, 9569/51822) of China (χ2=78.468, P=0.000), but also between the general (20.4%, 11991/58672) and the specialized (17.5%, 5196/29668) hospitals(χ2=107.473, P=0.000). Ultrasonic endoscope was used as routine practice in 10(17.5%, 10/57) general hospitals and 9(56.2%,9/16) specialized hospitals, and significant difference was found between them (χ2=9.721, P=0.002). A total of 4555 early gastric cancer patients received endoscopic therapy. The proportion of patients receiving endoscopic therapy was significantly different between the hospitals in the first-tier cities (36.0%, 2243/6233) and the other cities (21.1%, 2312/10954) (χ2=451.526, P=0.000), and between the hospitals with more than 800 gastric cancer patients per year (28.9%, 3434/11884) and those with less than 800 gastric cancer patients (21.1%, 1121/5303)(χ2=113.270, P=0.000). 37.1%(5270/14186) of early gastric cancer patients received laparoscopic surgery. The proportion of patients receiving laparoscopic surgery was 39.4%(3807/9651) in general hospitals and 32.3%(1463/4535) in specialized hospitals, whose difference was significant (χ2=68.244, P=0.000). The proportion of patients receiving laparoscopic surgery was 29.3%(1269/4328) in the first-tier cities and 40.6%(4001/9858) in the other cities, whose difference was significant as well(χ2=163.480, P=0.000). The proportion of patients receiving laparoscopic surgery was significantly different between the hospitals with more than 800 gastric cancer patients per year(34.5%, 3425/9929) and those with less than 800 gastric cancer patients (43.3%, 1845/4257) (χ2=100.057, P=0.000), and between the hospitals in the south (42.4%, 2552/6016) and those in the north (33.3%, 2718/8170) of China (χ2=124.296, P=0.000). 48.5%(6975) of early gastric cancer patients staged pT1a and 51.5%(7402) staged pT1b. Lymph node metastasis was found in 12.7%(1825/14377) of early gastric cancer. The lymph node metastasis rate of pT1a and pT1b was 5.7%(399/6975) and 19.3%(1426/7402), respectively. The lymph node metastasis rate of early gastric cancer varied from 12.7%(510/4017) in 2014 to 12.2%(668/5494) in 2015 and 13.3%(647/4866) in 2016. The data report of China Gastrointestinal Cancer Surgery Union partly reflects the epidemiologic characteristics, current status of diagnosis and treatment of early gastric in China.

Neoadjuvant chemotherapy before radical gastrectomy is preferred for locally advanced gastric cancer. To avoid the problematic use of pTNM for patients after neoadjuvant chemotherapy, the Union for International Cancer Control (UICC) and the American Joint Committee on Cancer (AJCC) gastric cancer TNM staging system (8th edition) added ypTNM for the first time. But patients achieving pathological complete response were not covered by the new ypTNM staging system. To investigate whether pathological complete response is associated with better outcome in gastric cancer, as was reported in rectal, breast and bladder cancer. We systematically searched the databases of PubMed, EMBASE, Web of Science and Cochrane Collaboration’s Central register of controlled trials from January 1988 to April 2015 for publications which reported outcomes of patients with and without pathological complete response (pCR) (pT0N0M0) to investigate whether pCR after neoadjuvant chemotherapy in gastric or gastroesophageal junction (GEJ) treated with radical surgery is associated with better survival. The primary outcome was overall survival (OS). The secondary outcome was disease-free survival (DFS). Both were measured with a relative risk (RR). A meta-analysis was performed using the fixed effects model. Forest plots and the Q test was used to evaluate overall heterogeneity for OS and DFS. A total of seven trials, 1143 patients were included and analyzed after neoadjuvant chemotherapy and radical surgery with no other preoperative treatment. The average rate of pCR was 6.74% (range: 3%-15%). The RR of patients who achieved pCR in the primary tumor and lymph nodes is 0.5 (95% confidence interval [CI], 0.25–0.98; p = 0.04), 0.34 (95% CI, 0.21–0.55; p<0.0001) and 0.44 (95% CI, 0.30–0.63; p<0.0001) for one-year-OS, three-year-OS and five-year-OS, respectively. The summary RR for three-year-DFS was 0.43 (95% CI, 0.25–0.72; p = 0.002). Patients with resectable gastric or GEJ cancer who achieved pCR after neoadjuvant chemotherapy can gain a better outcome than patients without pCR.

To compare the effect of neoadjuvant chemotherapy (NACT) with adjuvant chemotherapy (ACT) using oxaliplatin plus S-1 (SOX) or capecitabine (CapeOX) on gastric cancer patients with D2 lymphadenectomy. This was a two-by-two factorial randomized phase II-III trial, and registered on ISRCTN registry (No. ISRCTN12206108). Locally advanced gastric cancer patients were randomized to neoadjuvant SOX, neoadjuvant CapeOX, adjuvant SOX, or adjuvant CapeOX arms. Primary analysis was performed on an intention-to-treat (ITT) basis using overall survival (OS) as primary endpoint. This trial started in September 2011 and closed in December 2012 with 100 patients enrolled. Treatment completion rate was 56%, 52%, 38% and 30% in the four arms, respectively. NACT group had fewer dropouts due to unacceptable toxicity (P=0.042). Surgical complication rate did not differ by the four groups (P=0.986). No survival significant difference was found comparing NACT with ACT (P=0.664; 5-year-OS: 70% vs. 74% respectively), nor between the SOX and CapeOX groups (P=0.252; 5-year-OS: 78% vs. 66% respectively). Subgroup analysis showed SOX significantly improved survival in patients with diffuse type (P=0.048). No significant survival difference was found between NACT and ACT. SOX and CapeOX had good safety and efficacy as neoadjuvant regimens. Diffuse type patients may survive longer due to SOX.

Clinical practice showed that some advanced gastric cancer (AGC) patients achieved long-term survival after surgery, whereas some benefited from non-surgical treatment. In recent years, with the emergence of new drugs, diversity of treatment and development of multi-disciplinary team, the concept of conversion therapy comes into attention. Owing to diverse phenotypes with scattered cases, publications are mainly case reports or small sample studies from single centers, which makes it hard to acquire high-level evidence. On illustrating the definitions of AGC and conversion therapy, as well as integrating peritoneal metastasis, liver metastasis, No.16 lymph nodes metastasis, cytology positive and organs infiltration (T4b), we tried to classify AGC as resectable IIII( and unresectable IIII(. Resectable IIII( refers to lesions that could be resected as R0 evaluated by present diagnostic modalities, conditions of patients and therapeutic management, in which it is further classified as low-risk and high-risk subtypes, according to operation risk. If R0 is not achieved with the evaluation as above, it is classified as unresectable IIII(, in which it is further classified as conversed, partly conversed and non-conversed types after systemic therapy. For AGC patients with unresectable IIII(, operation must be performed more carefully, and the making of treatment protocols, the judge of operational time and the choice of operation procedure should be based on multi-disciplinary team. Such classification is aimed to facilitate clinical application and launch clinical trials, better to explore the characteristics of AGC.