Prognostic factors for gastric cancer after curative gastrectomy

Abstract

Introduction: Lymph node metastasis is the most important prognostic factor for patients with resected gastric cancer. The aim of this study was to determine other prognostic factors for gastric cancer after curative gastrectomy. Method(s): A single-center series of 115 patients with gastric cancer treated between 2010 and 2017 in a department of Medical Oncology in Tunisia was retrospectively investigated. Fifty patients (43.5%) underwent curative surgery. Result(s): Median age was 56 years old [26-89] with a female to male ratio of 1. 75.5% of the patients had a good performance status (0-1). 32% of tumors were complicated by digestive stenosis (52.2%). Increased tumor markers were found in 12.9% of the patients. 45.9% (n=17) of patients had peri-operative chemotherapy, 45.9% had surgery followed by adjuvant chemotherapy (from whom 24% had concomitant radiotherapy) and 8.1% had only neoadjuvant chemotherapy. Total gastrectomy was performed in 54% of the patients, with a D1 lymphadenectomy in 38.1% of the cases. Gastrectomy was considered R1 (positive surgical margin) in 12% of the cases. The mean number of removed lymph nodes was 16 [5-49]. The median lymph node ratio was of 0.33. This ratio was higher than 0.5 in 40% of cases. Most common stage was stage III (38.2%). Vascular emboli, perineural invasion and lymphatic emboli were present in respectively 19.4%, 16.7% and 8.6% of the cases. Perioperative chemotherapy regimens were FOLFOX (33.3%), LV5 FU2 Cisplatin (22.2%) and DCF (27.8%). The most common chemotherapy-induced toxicities ones were digestive intolerance (78.3%), neutropenia (56.5% with 45.5% of grade IV) and peripheric neuropathy (40.9%). Relapse rate was 30%. Distant relapses occurred in 64.3% of the cases. Median time to relapse was 13.5 months [1-39]. Patients who received FUFOL and TPF chemotherapy had a higher relapse rate than those who received other chemotherapy protocols (p=0.06). 60% of relapsed patients received palliative chemotherapy, 13.3% underwent palliative surgery, 6.7% had both and the others only had best supportive care. Median OS and PFS were 23 and 18 months. In univariate analysis, factors significantly associated with a poor OS were poor performance status (p=0.01), weight loss (p=0.05), cardia carcinomas (p=0.03), III and IV stages (p=0.01), a 0.5 lymph node ratio (p=0.006), R1 resection (p=0.01), high level of tumor markers (p=0.005), perineural invasion (p=0.008) and lymphatic emboli (p=0.004). Patients who had adjuvant radiotherapy had significantly better OS (p=0.02). In multivariate analysis, identified independent prognostic factors increased tumor markers (p=0.007) and perineural invasion (p=0.012). Conclusion(s): Almost half of our patients with gastric cancer are treated in a curative intent. Relapse rate is still high, and survival remains poor. Increased tumor markers at diagnosis and perineural invasion were both independent risk factors for OS in gastric patients after radical surgery.