Combined Gastrectomies: Survival Outcomes in Patients with Local Advanced Gastric Cancer

1. Combined Gastrectomies: Survival Outcomes
in Patients with Local Advanced Gastric Cancer
Kshivets Oleg Surgery Department, Roshal Hospital, Roshal, Moscow, Russia
P-15
OBJECTIVE: The survival of patients with local advanced gastric cancer (GC) takes
several months. Radical operations are extremely complex and remain the prerogative of
several best abdominal surgeons of the world. The search of optimal treatment plan for
GC patients (GCP) with stage T3-4N0-2M0 was realized. We examined factors in terms
of precise prediction of 5-year survival (5YS) of local advanced GCP after complete (R0)
combined gastrectomies (G).
METHODS: We analyzed data of 244 consecutive GCP (age=56.5±9.3 years; tumor
size=7±3 cm) radically operated and monitored in 1975-2020 (m=182, f=62; total
gastrectomy=75, distal gastrectomy=66, proximal gastrectomy=103, combined G with
resection of 1-7 adjacent organs (pancreas, liver, diaphragm, colon transversum,
splenectomy, small intestine, kidney, adrenal gland, etc.)=244; only surgery-S=166,
adjuvant chemoimmunotherapy-AT=78: 5FU+thymalin/taktivin; T3=131, T4=113; N0=105,
N1=37, N2=102, M0=244; G1=64, G2=54, G3=128. Multivariate Cox modeling, clustering,
SEPATH, Monte Carlo, bootstrap and neural networks computing were used to determine
any significant dependence.
RESULTS: Overall life span (LS) was 1617.1±1875.9 days and cumulative 5YS
reached 48.8%, 10 years – 41.2%, 20 years – 33.7%. 73 GCP lived more than 5 years
(LS=3870.8±2053.8 days), 32 – more than 10 years (LS=5589.5±2042.7 days). 106 GCP
died because of GC (LS=615.4±347.6 days). AT significantly improved 5YS (63.5% vs.
44%) (P=0.004). Cox modeling displayed that 5YS significantly depended on: N0-N12, AT,
blood cells, cell ratio factors (ratio between cancer cells-CC and blood cells
subpopulations), prothrombin index, protein, residual nitrogen, chlorides, blood group, Rh,
(P=0.000-0.043). Neural networks, genetic algorithm selection and bootstrap simulation
revealed relationships between 5YS and N0-12 (rank=1), healthy cells/CC (2),
erythrocytes/CC (3), thrombocytes/CC (4), lymphocytes/CC (5), stick neutrophils/CC (6),
eosinophils/CC (7), segmented neutrophils/CC (8), leucocytes/CC (9), monocytes/CC
(10). Correct prediction of 5YS was 100% by neural networks computing.
CONCLUSIONS: 5YS of local advanced GCP after combined radical procedures
significantly depended on: tumor characteristics, blood cell circuit, cell ratio factors,
biochemical factors, hemostasis system, anthropometric data, surgery type and adjuvant
treatment. Optimal strategies for local advanced GCP are: 1) availability of very
experienced abdominal surgeons because of complexity radical procedures; 2)
aggressive en block surgery and adequate lymph node dissection for completeness; 3)
precise prediction; 4) AT for GCP with unfavorable prognosis.
Cox Proportional Hazards Results,
GCP T3-4, n=244
Parameter
Estimate
Standard
Error
Chi-square P value 95% Lower CL 95% Upper CL
Blood Group 0.314825 0.107017 8.65439 0.003263 0.10508 0.524574
Rh -0.571752 0.251562 5.16566 0.023038 -1.06480 -0.078700
Eosinophils 0.722557 0.222019 10.59166 0.001136 0.28741 1.157707
Stick Neutrophils 0.762058 0.230126 10.96594 0.000928 0.31102 1.213095
Segmented Neutrophils 0.747819 0.230098 10.56248 0.001154 0.29683 1.198804
Lymphocytes 0.756933 0.229396 10.88788 0.000968 0.30733 1.206542
Monocytes 0.794499 0.235432 11.38823 0.000739 0.33306 1.255937
Residual Nitrogen 0.047100 0.018290 6.63166 0.010018 0.01125 0.082948
Protein 0.024703 0.011467 4.64108 0.031215 0.00223 0.047178
Chlorides -0.043362 0.016420 6.97392 0.008271 -0.07555 -0.011180
Prothrombin Index 0.021356 0.008889 5.77267 0.016277 0.00393 0.038778
Adjuvant Chemoimmunotherapy -0.959072 0.302898 10.02557 0.001544 -1.55274 -0.365403
Erythrocytes tot 0.106408 0.029480 13.02814 0.000307 0.04863 0.164188
Leucocytes tot -0.029456 0.014556 4.09514 0.043007 -0.05799 -0.000927
Segmented Neutrophils/Cancer Cells 0.332251 0.145735 5.19761 0.022618 0.04662 0.617887
Healthy Cells/Cancer Cells -0.167621 0.051619 10.54476 0.001165 -0.26879 -0.066449
Phase Transition N0—N12 1.349169 0.228340 34.91149 0.000000 0.90163 1.796707
Neural Networks: Baseline Error=0.000;
Area under ROC Curve=1.000;
Correct Classification Rate=100%, n=179
Rank Sensitivity
Phase Transition N0—N12 1 4771
Healthy Cells/Cancer Cells 2 4093
Erythrocytes/Cancer Cells 3 2400
Thrombocytes/Cancer Cells 4 2365
Lymphocytes/Cancer Cells 5 2200
Stick Neutrophils/Cancer Cells 6 1709
Eosinophils/Cancer Cells 7 1315
Segmented Neutrophils/Cancer Cells 8 1275
Leucocytes/Cancer Cells 9 1138
Monocytes/Cancer Cells 10 996
Bootstrap Simulation
(Number of Samples=3333)
Ran
k
Kendall Tau P
Phase Transition N0---N12 1 -0.220 0.000
Blood Chlorides 2 0.171 0.01
Hemorrhage Time 3 -0.145 0.01
Tumor Growth 4 -0.118 0.05
T3-4 5 -0.114 0.05
Tumor Size 6 -0.108 0.05
Survival Function
5-Year Survival=48.8%; 10-Year Survival=41.2%; 20-Year Survival=33.7%;
n=244; T3-4N0-2M0
Complete Censored
-5 0 5 10 15 20 25 30
Years after Combined Gastrectomies
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
CumulativeProportionSurviving
Cumulative Proportion Surviving (Kaplan-Meier)
5-Year Survival of GCP with N0=67.3%; 5-Year Survival of GCP with N1-2=34%;
P=0.000 by Log-Rank Test
Complete Censored
0 5 10 15 20 25 30
Years after Combined Gastrectomies
-0.2
0.0
0.2
0.4
0.6
0.8
1.0
CumulativeProportionSurviving
GCP with N1-2, n=139
GCP with N0, n=105
Cumulative Proportion Surviving (Kaplan-Meier)
5-Year Survival after Adjuvant Chemoimmunotherapy=63.5%; After Surgery=44%;
P=0.004 by Log-Rank Test
Complete Censored
0 5 10 15 20 25 30
Years after Combined Gastrectomies
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
CumulativeProportionSurviving
Only Surgery, n=166
Adjuvant Chemoimmunotherapy, n=78
Cumulative Proportion Surviving (Kaplan-Meier)
5-Year Survival of GCP with Exophytic Growth=61.9%;
5-Year Survival of GCP wth Endophytic Growth=41.2%;
P=0.001 by Log-Rank Test
Complete Censored
0 5 10 15 20 25 30
Years after Combined Gastrectomies
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
CumulativeProportionSurviving
Exophytic Growth, n=74
Endophytic Growth, n=163