Using the geriatric nutritional risk index to predict outcomes in older patients with remnant gastric cancer after gastrectomy: a retrospective multicenter study in Japan.

PURPOSE: This study investigated the prognostic value of the geriatric nutritional risk index (GNRI) in patients undergoing curative gastrectomy for remnant gastric cancer (RGC). METHODS: This multicenter retrospective study included 105 patients with RGC of ≥ 65 years of age who underwent curative gastrectomy at 10 institutions in Japan between January 2000 and December 2016. Postoperative complications, overall survival (OS), and disease-specific survival (DSS) were analyzed. RESULTS: Receiver operating curve analyses indicated that the optimal cutoff value of the GNRI for OS was 95.4. Patients were categorized into high and low GNRI groups based on the optimal GNRI cutoff value. The GNRI was significantly correlated with body mass index (p < 0.001), amount of bleeding (p = 0.021), Clavien-Dindo grade 5 postoperative complications (p = 0.040), death caused by primary disease (p = 0.010), and death caused by other diseases (p = 0.002). The OS and DSS were significantly worse in the low GNRI group. A low GNRI and T3 or deeper tumor invasion were independent prognostic factors for OS and DSS. CONCLUSIONS: The GNRI is a promising predictor of both short- and long-term outcomes in older patients with RGC.

The prognostic impact of the lymphocyte-to-C-reactive protein ratio in patients with unresectable or recurrent advanced gastric cancer treated with first- and second-line treatment.

PURPOSE: The goal of this study was to determine which markers are the most useful as first- and second-line pre-treatment markers in patients with unresectable or recurrent gastric cancer (URGC). METHODS: This study included 101 URGC patients who were treated with first- and second-line chemotherapy. Several prognostic scores based on nutrition and inflammation were analyzed using a receiver operating characteristic (ROC) analysis to determine the most useful prognostic marker. RESULTS: The lymphocyte-to-C-reactive protein ratio (LCR) had the highest area under the curve for both first- and second-line chemotherapy, according to an ROC analysis. An ROC analysis was used to determine the optimal LCR cut-off for the median survival time before first- and second-line chemotherapy, and patients were divided into high- and low-LCR groups. Patients with a high LCR had a significantly longer survival than those with a low LCR before first- and second-line chemotherapy (p = 0.004, p < 0.001, respectively). A low LCR before both first- and second-line chemotherapy was an independent poor prognostic factor in a multivariate analysis. CONCLUSIONS: URGC patients with a low LCR before both first- and second-line chemotherapy had a significantly worse prognosis than those with a high LCR in this study. Nutritional intervention during chemotherapy induction may lead to a better prognosis.

Impact of geriatric nutritional risk index on outcomes after gastrectomy in elderly patients with gastric cancer: a retrospective multicenter study in Japan.

BACKGROUND: Several studies investigated the utility of inflammation and nutritional markers in predicting the prognosis in patients with gastric cancer; however, the markers with the best predictive ability remain unclear. This retrospective study aimed to determine inflammation and nutritional markers that predicted prognosis in elderly patients over 75 years of age undergoing curative gastrectomy for gastric cancer. METHODS: Between January 2005 and December 2015, 497 consecutive elderly gastric cancer patients aged over 75 years underwent curative gastrectomy in 12 institutions. The geriatric nutritional risk index (GNRI), prognostic nutritional index, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, and C-reactive protein/albumin ratio were examined as prognostic markers for overall survival (OS) and disease-specific survival (DSS) using area under the curve (AUC) using receiver operating characteristic (ROC) curve analysis. RESULTS: The GNRI had the highest AUC and predictive value for both OS (0.637, p < 0.001) and DSS (AUC 0.645, p < 0.001). The study cohort was categorized into the high and low GNRI groups based on the optimal GNRI cut-off values for OS (97.0) and DSS (95.8) determined with the ROC analysis. For both OS and DSS, there was a significant correlation between the GNRI and several clinicopathological factors including age, body mass index, albumin, American Society of Anesthesiologists physical status score, depth of tumor invasion, lymph node metastasis, lymphatic invasion, pathological stage, operation duration, bleeding, procedure, approach, death due to primary disease, and death due to other disease. The GNRI remained a crucial independent prognostic factor for both OS (Hazard ratio [HR] = 1.905, p < 0.001) and DSS in multivariate analysis (HR = 1.780, p = 0.043). CONCLUSIONS: Among a panel of inflammation and nutritional markers, the GNRI exhibited the best performance as a prognostic factor after curative gastrectomy in elderly patients with gastric cancer, indicating its utility as a simple and promising index for predicting OS and DSS in these patients.

CA19-9 in combination with P-CRP as a predictive marker of immune-related adverse events in patients with recurrent or unresectable advanced gastric cancer treated with nivolumab.

BACKGROUND: Immune-check point inhibitors (ICPIs) for treatment of cancer patients sometimes induce potentially life-threatening immune-related adverse events (irAEs), which predict ICPIs treatment efficacy. Prediction of irAEs would be useful for management of irAEs and prediction of ICPIs efficacy. This study aimed to determine predictors of irAEs in patients with recurrent or unresectable advanced gastric cancer (RUGC) treated with nivolumab. METHODS: Seventy-eight RUGC patients treated with nivolumab at nine institutions between January 2017 and April 2020 were included in this study. The usefulness of specific blood test results as predictors of irAEs was evaluated. RESULTS: We observed irAEs in 15 (19.2%) patients. The disease control rate was significantly higher in the patients with irAEs than in those without (86.7% vs. 42.9%; P < 0.001). The median progression-free survival was significantly longer for patients with irAEs than for patients without (4.9 vs. 2.6 months; P = 0.018). The median survival time was longer for patients with irAEs than for those without (9.4 vs. 5.8 months; P = 0.041). The receiver operating characteristic (ROC) curves for irAEs indicated that the area under the curve (AUC) of carbohydrate antigen 19-9 (CA19-9) was highest (0.692; P = 0.022), followed by that for the platelet count × serum C-reactive protein (P-CRP) value (0.680; P = 0.032). The AUC for the CA19-9 + P-CRP combination was 0.782, which was more useful than that for either component and significantly associated with overall survival of nivolumab-treated RUGC patients. CONCLUSIONS: The CA19-9 + P-CRP combination was predictive of irAEs and prognosis in RUGC patients.

Duration of Postoperative Fever as a Simple and Useful Prognostic Indicator in Gastric Cancer Patients.

BACKGROUND: Postoperative inflammation is associated with cancer progression in several cancers. However, the prognostic significance of postoperative fever remains unclear in gastric cancer patients. METHODS: We enrolled 442 patients with a histopathological diagnosis of gastric adenocarcinoma who underwent curative surgery. RESULTS: The mean duration of postoperative fever ≥ 37°C was 8.7 days (range: 0-186 days) and significantly longer in patients with advanced gastric cancer, venous invasion, and open or total gastrectomy vs. patients with early gastric cancer (P = 0.0072), no venous invasion (P = 0.025), laparoscopic gastrectomy (P = 0.027), and either proximal or distal partial gastrectomy (P = 0.0015). Five-year overall survival rates were 69.5% vs. 83.6% in the prolonged postoperative fever group (≥ 6 days of ≥ 37°C) vs. the nonprolonged group (< 6 days of ≥ 37°C), respectively (P = 0.0008). In patients without Clavien-Dindo classification postoperative infectious complications grade ≥ 2, 5-year overall survival was 69.7% vs. 84.0% in patients with prolonged postoperative fever vs. those without, respectively (P = 0.0067). Five-year disease-specific survival was 85.9% vs. 93.1% in patients with prolonged fever vs. those without, respectively (P = 0.041). Multivariate analysis indicated that postoperative fever was an independent prognostic indicator. CONCLUSION: Postoperative fever ≥ 37°C duration may be useful in predicting prognosis in gastric cancer patients.

Natural History of Exophytic Type Gastrointestinal Stromal Tumor: A Case Report.

Gastrointestinal stromal tumor (GIST) is the most common submucosal tumor of the stomach. GISTs are often detected by esophagogastroduodenal endoscopy. We have previously reported on endoscopically invisible medium-sized exophytic type GISTs. We present here a case of small exophytic GIST detected by transabdominal ultrasonography (TUS) in which the natural history of the tumor could be traced retrospectively through incidental findings obtained during follow-up for intraductal papillary mucinous neoplasm by magnetic resonance of imaging or computed tomography over about 10 years. The tumor appeared 7 years before its detection, and the doubling time was calculated as 6.9 years. In conclusion, low-risk exophytic GIST was estimated to have taken at least about 7 years to reach a size detectable by TUS.

Prognostic Significance of Pre- and Postoperative Lymphocyte Counts in Patients with Gastric Cancer.

BACKGROUND: Although preoperative lymphopenia is reportedly a prognostic factor in cancer patients, the association between postoperative lymphopenia and patient prognosis has not been widely studied. METHODS: We enrolled 352 patients who underwent surgery for gastric cancer (GC) between January 2005 and April 2013 to analyze correlations among pre- and postoperative lymphocyte counts (LCs) and prognosis in GC patients. RESULTS: Pre- and postoperative (obtained 1 day after surgery) LCs were significantly correlated (r = 0.496, p < 0.0001). Pre- and postoperative LCs of elderly patients were significantly lower than those of non-elderly patients. Postoperative lymphocyte count was significantly lower in patients with a differentiated tumor than in those with an undifferentiated tumor. Based on the results of receiver operating characteristic analysis, patients were classified into subgroups as: preoperative LC ≥1,676 (pre-LCHigh), preoperative LC <1,676 (pre-LCLow); and as postoperative LC ≥855 (post-LCHigh), and postoperative LC <855 (post-LCLow). Five-year overall survival rates significantly differed between pre-LCHigh (82.5%) and pre-LCLow (71.6%) groups (p = 0.023); and also between the post-LCHigh (81.5%) and post-LCLow (69.5%) groups (p = 0.0072). The 5-year disease specific survival rates were 91.3 and 82.4% in patients with post-LCHigh and those with post-LCLow, respectively, and differences were statistically significant (p = 0.015). Multivariate analysis indicated that postoperative lymphocyte count was an independent prognostic indicator, along with age, gender, tumor size, lymph node metastasis, and venous invasion. CONCLUSIONS: Postoperative lymphocyte count is a useful predictive factor for prognosis in GC patients.

Postoperative ratio of the maximum C-reactive protein level to the minimum peripheral lymphocyte count as a prognostic indicator for gastric cancer patients.

PURPOSE: Inflammation, together with immune and nutritional status, are associated with the progression of various cancer types. We evaluated the prognostic significance of the postoperative ratio (post-CLR) of the maximum C-reactive protein value (post-CRPMax) to the minimum peripheral lymphocyte count (post-LCMin) in patients with gastric cancer (GC). METHODS: The subjects of this retrospective study were 227 patients who underwent curative surgery for histopathologically diagnosed gastric adenocarcinoma. RESULTS: The 5-year overall survival (OS) rates differed significantly between the post-CLRHigh (≥ 152.6) group and the post-CLRLow (< 152.6) group for all patients (45.0% vs. 68.4%, respectively; P < 0.001). The 5-year disease-specific survival (DSS) rates were also significantly related to post-CLR for all patients, (80.6% vs. 64.3% for the post-CLRLow and the post-CLRHigh groups, respectively; P = 0.002). Among patients without infectious complications, the CLR affected both the 5-year OS rate (48.4% vs. 69.2% for the post-CLRHigh and the post-CLRLow groups, respectively; P = 0.006) and the 5-year DSS rate (80.2% vs. 67.0% for the post-CLRLow and the post-CLRHigh groups, respectively; P = 0.027). Multivariate analysis revealed that post-CLR was an independent prognostic indicator for both the OS and DSS of all patients. CONCLUSIONS: Our finding show that the post-CLR can help predict the prognosis of GC patients.

Therapeutic Value of Lymph Node Dissection Along the Superior Mesenteric Vein and the Posterior Surface of the Pancreatic Head in Gastric Cancer Located in the Lower Third of the Stomach.

BACKGROUND: Therapeutic value of lymph node dissection along the superior mesenteric vein (14v) and the posterior surface of the pancreatic head (13) remains unclear in gastric cancer patients. METHODS: We reviewed 355 patients with advanced gastric cancer in the lower third of the stomach who had undergone gastrectomy at our hospital. RESULTS: The frequency of lymph node (LN) metastasis was 10.2% and 7.4% in stations 13 and 14v, respectively. The frequency of station 13 metastasis was 26.8% for T3/T4 tumors with group 2 LNs metastasis and 1.4% for all other tumors. The frequency of station 14v metastasis was 22.2% for T3/T4 tumors with group 2 LNs metastasis and 1.8% for all other tumors. The therapeutic values for dissecting LN stations 13 and 14v were 1.9 and 0.9, respectively, similar to the therapeutic value for group 2 LN dissection. CONCLUSION: Because metastasis to stations 13 and 14v occurs frequently in patients with T3/T4 gastric cancer located in the lower third of the stomach who also have metastasis to group 2 LNs, stations 13 and 14v should be dissected in these patients.

Less Invasive Surgery for Remnant Stomach Cancer After Esophago-proximal Gastrectomy with ICG-guided Blood Flow Evaluation: A Case Report.

The standard procedure for remnant gastric cancer after esophago-proximal gastrectomy is total resection of the remnant stomach considering blood supply. However, sometimes surgery may be too invasive due to severe adhesion in the thoracic and mediastinal cavity. The blood supply to the remnant stomach depends on the right gastroepiploic artery and the right gastric artery. Therefore, preservation of the proximal region of the remnant stomach is thought to be anatomically impossible. We report a case of remnant gastric cancer that developed more than 12 years after lower thoracic esophagectomy plus proximal gastrectomy for Siewert Type I squamous cell carcinoma. We used intra-operative indocyanine green (ICG) venous-injection to evaluate blood flow and distal gastrectomy of the remnant stomach was performed by preserving the proximal stomach in the thoracic cavity through an abdominal approach. There were no complications of the remnant stomach or the anastomosis to the jejunum after surgery. In this case, we focused on the blood supply by collateral circulation through the anastomotic line from the remnant esophagus. After confirming blood supply with intra-operative evaluation using ICG fluorescence, less-invasive distal gastrectomy was successfully performed. As the intra-operative ICG-based evaluation for blood supply is a simple and safe method, it might be useful for determining the resection margin of various organs and be effective for the introduction of less invasive surgery. Here, we report a case and a review of the literature.

Successful repair using thymus pedicle flap for tracheoesophageal fistula: a case report.

BACKGROUND: Treatment for tracheoesophageal fistula (TEF), a life-threatening complication after esophagectomy, is challenging. CASE PRESENTATION: A 75-year-old man with thoracic esophageal cancer underwent subtotal esophagectomy and gastric tube reconstruction through the post-mediastinal root after neoadjuvant chemotherapy. Owing to postoperative anastomotic leakage, an abscess formed at the anastomotic region. Sustained inflammation from the abscess caused refractory TEF between the esophagogastric anastomotic site and membrane of the trachea, and several conservative therapies for TEF failed. Hence, the patient underwent surgery including division of the fistula, direct suturing of the leakage sites, and reinforcement with the flap of the thymus pedicle. As a result, the abscess and TEF disappeared after surgery and the patient was immediately administered an oral diet and discharged home 103 days after initial surgery. CONCLUSIONS: Although pedicle flaps for the reinforcement of TEF are usually obtained from muscle or pericardium, these flaps need enough lengths to overcome moving distance. We are the first in the existing literature to have successfully treated TEF with surgical repair using a thymus flap located close to TEF. The thymus pedicle might be another candidate for the reinforcement flap in TEF.

Postoperative Serum Albumin is a Potential Prognostic Factor for Older Patients with Gastric Cancer.

BACKGROUND: The incidence of gastric cancer (GC) among older adults is increasing. Therefore, determining postoperative age-associated prognostic factors is clinically important. This study retrospectively investigated the prognostic significance of serum albumin level in older GC patients. METHODS: We enrolled 135 patients aged ≥ 75 years, who underwent gastrectomies with histopathological diagnoses of gastric adenocarcinoma. RESULTS: Preoperative albumin (pre-Alb) levels in patients with advanced GC and stage III/IV GC were significantly lower than those in patients with early GC (P = 0.0032) and stage I/II GC (P = 0.006), respectively. Postoperative albumin (post-Alb) levels (measured 1 month after surgery) in male patients and in patients with advanced GC were significantly lower than those in female patients (P = 0.024) and those with early GC (P = 0.044), respectively. Post-Alb levels of patients who died of other diseases were significantly lower than those who were still living (P = 0.0004). Prognosis of patients with high post-Alb levels (≥ 4g/dL) was significantly better than that of patients with low post-Alb levels (< 4g/dL; P = 0.045); and in multivariate analysis, post-Alb level was an independent prognostic indicator. CONCLUSION: Post-Alb level is a useful predictive factor for the prognosis of older GC patients. Postoperative nutritional support might help improve the prognosis of older GC patients.

Prognostic Significance of Platelet-Based Inflammatory Indicators in Patients with Gastric Cancer.

BACKGROUND: Thrombocytosis develops in association with malignant tumors and may reflect the inflammation status in cancer patients. This study retrospectively investigated the prognostic significance of two platelet-based inflammatory indicators, the platelet × C-reactive protein multiplier value (P-CRP), and platelet-lymphocyte ratio (PLR), in gastric cancer patients. METHODS: The 453 enrolled patients had a histopathological diagnosis of gastric adenocarcinoma and underwent curative surgery. RESULTS: P-CRP correlated significantly with age, tumor size, depth of invasion, lymph node metastasis, and disease stage. A high PLR correlated significantly with tumor size, depth of invasion, lymph node metastasis, lymphatic involvement, venous involvement, and disease stage. In the ROC analysis, the optimal cutoff value of P-CRP and PLR was 3.689 and 173.3, respectively. Five-year survival rates were 62.9 and 82.1% in patients with P-CRPHigh (≥3.689) and P-CRPLow (<3.698), respectively (P < 0.0001). Five-year survival rates were 66.3 and 81.3% in patients with PLRHigh (≥173.3) and PLRLow (<173.3), respectively (P = 0.0022). The prognosis of the P-CRPHigh/PLRHigh group was significantly worse than that of the P-CRPHigh or PLRHigh and P-CRPLow/PLRLow groups in terms of overall survival (P < 0.0001) and disease-specific survival (P = 0.029). In a multivariate analysis, the combination of P-CRP and PLR was an independent prognostic indicator. CONCLUSIONS: The combination of P-CRP and PLR may be useful in predicting prognosis in gastric cancer patients.

Combined analysis of the pre- and postoperative neutrophil-lymphocyte ratio predicts the outcomes of patients with gastric cancer.

PURPOSE: The neutrophil-lymphocyte ratio (NLR) is a biochemical marker of the systemic inflammatory response and has been associated with prognosis for various types of cancer. This retrospective study investigates the relationship between the pre- and postoperative NLR and the prognosis of gastric cancer patients. METHODS: The subjects were 280 patients who underwent curative surgery for histopathologically diagnosed gastric adenocarcinoma. RESULTS: The preoperative NLR was significantly correlated with tumor size, tumor depth, lymphatic invasion, venous invasion, and disease stage. In contrast, there was no correlation between the postoperative NLR and the various clinicopathological variables. Prognosis was significantly worse for patients with a high preoperative NLR than for those with a low preoperative NLR. Prognosis was also significantly worse for patients with a high postoperative NLR than for those with a low postoperative NLR. Furthermore, the prognosis was worse for gastric cancer patients whose pre- and postoperative NLRs were both high. Multivariate analysis indicated that a high pre- and postoperative NLR was an independent prognostic indicator. CONCLUSIONS: The combination of pre- and postoperative NLRs appears to be useful for predicting the prognosis of gastric cancer patients.

Risk and incidence of perioperative deep vein thrombosis in patients undergoing gastric cancer surgery.

BACKGROUND AND PURPOSE: Venous thromboembolism (VTE) is a potentially fatal perioperative complication. Understanding the risk factors for deep vein thrombosis (DVT) and initiating appropriate prophylaxis is pivotal for reducing the risk of VTE. The purpose of this study was to clarify the perioperative risk factors for DVT in patients undergoing surgery for gastric cancer. METHODS: We reviewed the findings of lower limb ultrasonography performed in 160 patients who underwent gastrectomy for gastric cancer. RESULTS: The preoperative and postoperative incidence of DVT was 4.4% (7/160) and 7.2% (11/153), respectively. All postoperative DVTs were of the distal type, whereas preoperative DVTs were of the proximal (n = 3) and distal type (n = 4). None of the patients suffered symptomatic VTE. Multivariate analysis indicated that depth of invasion and D-dimer concentration were independent risk factors for preoperative DVT and that gender and performance status were risk factors for postoperative DVT. Receiver operating characteristic analysis revealed that the optimal cut-off D-dimer concentration was 1.4 µg/mL. CONCLUSIONS: The incidence of perioperative DVT was low for patients undergoing gastric cancer surgery. Therefore, the risk-stratified application of perioperative pharmacologic thromboprophylaxis is thought to be more appropriate than routine pharmacologic thromboprophylaxis for Japanese patients undergoing surgery for gastric cancer.

Prognostic Significance of the Preoperative Ratio of C-Reactive Protein to Albumin and Neutrophil-Lymphocyte Ratio in Gastric Cancer Patients.

BACKGROUND: The ratio of C-reactive protein to albumin (CRP/Alb) is a biochemical marker of systemic inflammatory response and has been associated with poor survival in cancer. This study retrospectively investigated the relationship between the CRP/Alb ratio and prognosis in gastric cancer patients. METHODS: This study enrolled 453 patients with a histopathological diagnosis of gastric adenocarcinoma who underwent curative surgery. RESULTS: A statistically significant weak correlation was observed between CRP/Alb ratio and neutrophil/lymphocyte ratio (NLR) (r = 0.19; P < 0.0001). There were statistically significant correlations between high CRP/Alb ratio and age (P = 0.0004), tumor size (P = 0.02), depth of invasion (P = 0.012), and lymph node metastasis (P = 0.022). A high NLR was significantly correlated with age (P = 0.0027), tumor size (P = 0.0006), depth of invasion (P < 0.0001), lymphatic involvement (P = 0.0031), venous involvement (P = 0.0022), and stage of disease (P = 0.0024). Based on results by receiver operating characteristic analysis, patients were divided as follows: CRP/Alb ratio ≥ 0.0232 (CARHigh), CRP/Alb ratio < 0.0232 (CARLow), NLR ≥ 2.43 (NLRHigh), and NLR < 2.43 (NLRLow). Five-year survival rates of patients with both CARHigh and NLRHigh, either CARHigh or NLRHigh, and both CARLow and NLRLow were 59.6, 75.8, and 87.5%, respectively, with statistically significant differences (P < 0.0001). Multivariate analysis revealed that the combination of CRP/Alb ratio and NLR was an independent prognostic indicator. CONCLUSIONS: The combination of CRP/Alb ratio and NLR may be useful in predicting prognosis in gastric cancer patients.

Combined analysis of the preoperative and postoperative prognostic nutritional index offers a precise predictor of the prognosis of patients with gastric cancer.

PURPOSE: The prognostic nutritional index (PNI) is considered useful for predicting the prognosis of patients with gastric cancer (GC). This retrospective study investigated the relationship between both the pre- and postoperative PNI and the prognosis of GC patients. METHODS: The subjects of this study were 254 patients who underwent curative surgery for histopathologically diagnosed GC. RESULTS: Patients were divided according to their pre- and postoperative PNI as follows: preoperative PNI of ≥ 52 (pre-PNIHigh), preoperative PNI of < 52 (pre-PNILow), postoperative PNI of ≥ 49 (post-PNIHigh), and postoperative PNI of < 49 (pre-PNILow). Both pre- and postoperative PNI were significantly associated with GC prognosis. Patients were then divided as follows: group A, patients with pre-PNIHigh and post-PNIHigh; group B, patients with either pre-PNIHigh and post-PNILow or pre-PNILow and post-PNIHigh; and group C, patients with pre-PNILow and post-PNILow. The 5-year survival rates were 100.0, 83.0, and 67.1% for groups A, B, and C, respectively. Multivariate analysis indicated that the combination of pre- and postoperative PNI was an independent prognostic indicator. CONCLUSIONS: Combined analysis of the pre- and postoperative PNI offers accurate information about the prognosis of patients with GC.

Highly Activated PD-1/PD-L1 Pathway in Gastric Cancer with PD-L1 Expression.

BACKGROUND: A recent study demonstrated that immune-checkpoint molecules are associated with tumoral immune evasion. MATERIALS AND METHODS: Programmed cell death protein 1 (PD-1) expression on CD4+ and CD8+ T-cells obtained from gastric cancer tissue was evaluated by multicolor flow cytometry. Immunohistochemical staining was also performed to evaluate programmed cell death ligand-1 (PD-L1) expression on gastric cancer cells. RESULTS: There were statistically significant correlations between PD-L1 expression and age, histology, tumor size, depth of invasion, lymph node metastasis, lymphatic vessel invasion, venous invasion, and disease stage. The 5-year survival rates of patients with and without PD-L1-positive tumors were 48.9% and 80.7%, respectively, and the difference was statistically significant. Multivariate analysis indicated that PD-L1 expression was an independent prognostic indicator. The frequency of PD-1-positive CD4+ and CD8+ T-cells from gastric cancer tissue with PD-L1 expression was significantly more than that from gastric cancer tissue without PD-L1 expression. CONCLUSION: PD-L1 expression was related to a poor prognosis in patients with gastric cancer. Furthermore, PD-1 expression on T-cells was up-regulated in patients with tumors with PD-L1 expression.

Gross Appearance and Curability Are Predictive Factors of a Better Prognosis After Gastrectomy in Gastric Cancer Patients with Metastasis to the Adjacent Peritoneum of the Stomach.

BACKGROUND: Gastric cancer patients with peritoneal metastasis have an extremely poor prognosis. The aim of the current study was to clarify the predictive factors of a better outcome in gastric cancer patients with peritoneal metastasis. METHODS: We analyzed the records of 2262 gastric adenocarcinoma patients who underwent gastrectomies at our institution between January 1980 and December 2010. RESULTS: The 5-year survival rates for advanced gastric cancer patients with P1 (n = 43), P2 (n = 56), and P3 (n = 36) metastasis were 16.3%, 0%, and 0%, respectively. The prognosis of P1 gastric cancer patients was significantly better than that of either P2 (P = 0.0003) or P3 patients (P < 0.0001). A multivariate analysis identified gross appearance and curability as independent prognostic indicators in P1 gastric cancer patients. In fact, the prognosis was good for patients in whom an R0/1 resection had been performed and with tumors having a gross appearance of other than type 4, with a 40% 5-year survival rate and a 29-month median survival time. CONCLUSION: Our data indicated a good prognosis for P1 patients in whom an R0/1 resection could be performed and with tumors having a gross appearance of other than type 4. Therefore, radical surgery and adequate adjuvant chemotherapy should be performed in these patients.

Thoracic Esophagus Cancer Revealing a Tracheal Diverticulum.

Tracheal diverticulum is rarely encountered in a clinical setting since almost all patients are asymptomatic. However, its presence may become a problem during esophageal cancer operations in terms of anesthesia and lymph node dissection of superior mediastinum lymphadenectomy. A 70-year-old man with esophageal cancer was referred to our hospital. During thoracoscopic subtotal esophagectomy, we found a cystic lesion connected to the right posterior wall of the trachea. We evaluated the preoperative computed tomography scan during surgery and made a diagnosis of tracheal diverticulum because of the presence of paratracheal air cysts, which had not been noticed preoperatively. It was resected by a linear stapler and the postoperative course of the patient was uneventful. A careful preoperative evaluation of computed tomography and operation are necessary to avoid injury of tracheal diverticulum during thoracoscopic esophagectomy for esophageal cancer revealing a tracheal diverticulum.