Molecular and pathological analyses of gastric stump cancer by next-generation sequencing and immunohistochemistry

Gastric stump cancer (GSC) has distinct clinicopathological characteristics from primary gastric cancer. However, the detailed molecular and pathological characteristics of GSC remain to be clarified because of its rarity. In this study, a set of tissue microarrays from 89 GSC patients was analysed by immunohistochemistry and in situ hybridisation. Programmed death ligand 1 (PD-L1) was expressed in 98.9% of tumour-infiltrating immune cells (TIICs) and 6.7% of tumour cells (TCs). Epstein–Barr virus (EBV) was detected in 18 patients (20.2%). Overexpression of human epidermal growth factor receptor 2 and deficiency of mismatch repair (MMR) protein expression were observed in 5.6% and 1.1% of cases, respectively. Moreover, we used next-generation sequencing to determine the gene mutation profiles of a subset of the 50 most recent patients. The most frequently mutated genes were TP53 (42.0%) followed by SMAD4 (18.0%) and PTEN (16.0%), all of which are tumour suppressor genes. A high frequency of PD-L1 expression in TIICs and a high EBV infection rate suggest immune checkpoint inhibitors for treatment of GSC despite a relatively low frequency of deficient MMR gene expression. Other molecular characteristics such as PTEN and SMAD4 mutations might be considered to develop new treatment strategies.

The option of surgery for gastric stump cancer in patients who have previously undergone pancreaticoduodenectomy

Gastric stump cancer is a carcinoma which forms no earlier than 5years after surgery for benign disease. The incidence ranges from 2.4 to 5% among patients with stomach cancer. Previous operations lead to the emergence of an adhesive process in the abdominal cavity, changes in the anatomy and topography of the abdominal organs, as well as the development of new ways of lymph outflow. These factors lead to the re-surgery becomes technically more complicated and requires high professional training from the surgeon. Of particular surgical interest is the issue of restoration of the digestive tract, which directly depends on the nature and volume of the previous surgery. In this paper, the authors describe cases of surgical treatment of gastric stump cancer in two patients, who had previously undergone pancreaticoduodenectomy.

Laparoscopic completion total gastrectomy as a standardized procedure for gastric stump cancer: a case control study

Objective Complete gastrectomy for gastric stump cancer (GSC) can be challenging due to severe adhesions; therefore, advanced techniques are required when being performed by laparoscopic surgery. This study aimed to evaluate the clinical outcomes of laparoscopic completion total gastrectomy (LCTG) for the treatment of GSC. Methods Patient records from January 2010 to October 2018 were retrospectively evaluated. The patients were classified into two groups depending on whether they underwent open or laparoscopic gastrectomy. We compared patient characteristics; operative, clinical, and pathological data between the groups. Results Twenty open and 17 LCTGs were performed. Laparoscopic gastrectomy resulted in a significantly longer operation time (230 vs. 182.5 min; p = 0.026), lower blood loss (14 vs. 105 mL; p < 0.001), and shorter period to the first flatus passage (2 vs. 3 days; p < 0.001) than open gastrectomy. No significant differences in the number of retrieved lymph nodes, duration of hospital stay, complication rate, and postoperative analgesic usage between the two groups were observed. No patients required conversion to open surgery in the laparoscopic-treatment group. Pathological findings revealed that the laparoscopic group had a smaller tumor size (not pathological T category) and fewer metastatic lymph nodes than the open group leading to an earlier distribution of the pathological stage in the laparoscopic group. Conclusions LCTG for the treatment of GSC was safely conducted with fewer complications and mortalities than previously reported results. Advanced technologies and sophistication of laparoscopic skills may further yield minimal invasiveness with better short-term outcome.

Gastric Stump Cancer: Demanding a More Suitable Definition and TNM Staging System

BackgroundThe incidence of gastric stump cancer (GSC) following resection of gastric cancer has increase. However, the definition between GSC and recurrent gastric cancer (RGC) is still being debated. This study was conducted to compare the clinicopathological characteristics and outcome for this two groups.MethodsThe investigators retrospectively reviewed patients in the Surveillance Epidemiology and End Results (SEER) databases from 1975 to 2016 to identify patients who underwent resection of gastric cancer subsequently experienced metachronous gastric cancer. GSC was defined as cancer occurring in remnant stomach of ≥10 years after gastrectomy, while RGC was defined as <10 years after gastrectomy. T-test, Pearson χ2-test and Kaplan-Meier estimator method was used in the present study.ResultsAmong the 167,747 gastric cancer patients, 1,006 (0.6%) patients were diagnosed multiple gastric cancer, 93 patients met the GSC criterion, and 282 patients met the RGC criterion. The mean time interval between the initial cancer and second cancer for GSC was 13.34 years and 4.24 years for RGC. Male gender (P=0.003), younger age (60.1 years old vs. 65.9 years old, P<0.001) developed more frequently in GSC group. The median OS in GSC group was 20.0 months compared with 16.0 months for RGC group (p=0.302). Surgery treatment or not, the median OS have statistically significant (in RGC group, 64.0 months vs. 10.0 months, P＜0.001; 33 months vs. 13 months, P=0.014 in GSC group).ConclusionsIn our definition of GSC and RGC, the OS were not statistically significant and gastrectomy may be the appropriate treatment for this two groups. It may demand for a more suitable definition and TNM staging system for GSC.

Gastric Stump Cancer: Demanding a More Suitable Definition and TNM Staging System

BackgroundThe incidence of gastric stump cancer (GSC) following resection of gastric cancer has increase. However, the definition between GSC and recurrent gastric cancer (RGC) is still being debated. This study was conducted to compare the clinicopathological characteristics and outcome for this two groups.Patients and MethodsThe investigators retrospectively reviewed patients in the Surveillance Epidemiology and End Results (SEER) databases from 1975 to 2016 to identify patients who underwent resection of gastric cancer subsequently experienced metachronous gastric cancer. GSC was defined as cancer occurring in remnant stomach of ≥10 years after gastrectomy, while RGC was defined as <10 years after gastrectomy. T-test, Pearson χ2-test and Kaplan-Meier estimator method was used in the present study.ResultsAmong the 167,747 gastric cancer patients, 1,006 (0.6%) patients were diagnosed multiple gastric cancer, 93 patients met the GSC criterion, and 282 patients met the RGC criterion. The mean time interval between the initial cancer and second cancer for GSC was 13.34 years and 4.24 years for RGC. Male gender (P=0.003), younger age (60.1 years old vs. 65.9 years old, P<0.001) developed more frequently in GSC group. The median OS in GSC group was 20.0 months compared with 16.0 months for RGC group (p=0.302). Surgery treatment or not, the median OS have statistically significant (in RGC group, 64.0 months vs. 10.0 months, P＜0.001; 33 months vs. 13 months, P=0.014 in GSC group).ConclusionIn our definition of GSC and RGC, the OS were not statistically significant and gastrectomy may be the appropriate treatment for this two groups. It may demand for a more suitable definition and TNM staging system for GSC.

Laparoscopic Completion total Gastrectomy as an Alternative Procedure for Gastric Stump Cancer: A Case Control Study

BackgroundComplete gastrectomy for gastric stump cancer can be challenging due to severe adhesions; therefore, advanced techniques are required to perform laparoscopic surgery. This study aimed to evaluate the clinical outcomes of laparoscopic completion total gastrectomy for the treatment of gastric stump cancer.MethodsPatient records from January 2010 to October 2018 were retrospectively evaluated. The patients were divided into two groups depending on whether they underwent open or laparoscopic gastrectomy. We compared patient characteristics; operative, clinical, and pathological data; survival rates; and prognosis between the groups.ResultsTwenty open and 17 laparoscopic completion total gastrectomies were performed. No significant differences in the distribution of the clinical T and N categories, clinical stage, and reconstruction methods of the initial gastrectomy between the two groups were observed. Laparoscopic gastrectomy resulted in a significantly longer operation time (230 vs. 182.5 min; p = 0.026), lower blood loss (14 vs. 105 mL; p = 0.0000179), and shorter period to the first flatus passage (2 vs. 3 days; p = 0.0000401) than open gastrectomy. No significant differences in the number of retrieved lymph nodes, duration of hospital stay, complication rate, and postoperative analgesic usage between the two groups were observed. No patients required conversion to open surgery in the laparoscopic-treatment group. Pathological findings revealed that the laparoscopic group had a smaller tumor size (not pathological T category) and less metastatic lymph nodes than the open group; this led to an earlier distribution of the pathological stage and better overall or disease-free survivals in the laparoscopic group.ConclusionsLaparoscopic completion total gastrectomy was safely conducted without complications and mortality implicating the oncological validity for the treatment of gastric stump cancer. With sophistication of laparoscopic skills and advanced technologies, laparoscopic completion total gastrectomy may be the best way to perform less invasive surgery in terms of decreased blood loss and earlier recovery of intestinal peristalsis.

Completion total gastrectomy with intracorporeal robot-sewn esophago-jejunal anastomosis

Many technical reports concern minimally invasive surgery for stomach cancer; however, there is poor evidence about employing this approach for gastric stump cancer, which can arise at the anastomotic site in patients who have undergone previous partial gastrectomy for benign diseases such as gastric ulcer. Such surgery was quite common before the introduction of proton pump inhibitors (PPIs), and so today, according to different statistics, gastric stump cancer can be revealed in up to 8% of these patients. This report seeks to highlight the possibility of employing a minimally invasive approach in patients who already had an operation for gastric resection. The video shows technical notes about the hybrid laparoscopic-robotic approach performed in a patient who previously underwent open distal gastrectomy. Is the previous laparotomy an absolute or relative counterindication to reperform a surgery through a minimally invasive approach?