The management of gastric cancer has become increasingly complex, highlighting the importance of clinical guidelines to ensure standardized care. The Second Brazilian Consensus on Gastric Cancer was developed to guide clinical practice across the country.
The aim of this study was to evaluate the degree of implementation of the 2nd Brazilian Consensus recommendations in cancer reference centers in Brazil.
This multicenter study involved 18 cancer centers that prospectively collected data over a one-year period. Notably, 21 key statements from the Consensus were assessed. Adherence was defined as following the recommendation in more than 80% of applicable cases.
Of the 21 statements, 11 (52.4%) met the predefined adherence threshold. The selective use of endoscopic ultrasound and PET-CT was consistent with the recommendations. However, diagnostic laparoscopy was underutilized, performed in only 24.7% of patients. Preoperative nutritional therapy, another key recommendation, was provided in just 42% of cases. D2 lymphadenectomy was performed in 79.8% of surgeries, but only 63.3% of specimens included ≥25 lymph nodes, the recommended minimum for adequate staging. Minimally invasive surgery (MIS) was performed in approximately 25% of early distal tumors but was rarely used in advanced proximal tumors. Despite not being recommended for early stage tumors, omentectomy and bursectomy were still performed in a significant number of T1/T2 cases. Preoperative chemotherapy was used in 35.4% of distal tumors ≥IB and 54.3% of proximal tumors, showing partial adherence to this recommendation.
Just over half of the II Brazilian Consensus recommendations were implemented in routine practice. There was strong adherence to D2 lymphadenectomy and MIS for early distal tumors. However, there is still room for improvement in areas such as diagnostic laparoscopy, nutritional support, adequate lymph node retrieval, and using more neoadjuvant chemotherapy to enhance care and follow national guidelines.
The development of consensus statements and clinical guidelines supports decision-making in clinical practice. However, recommendations formulated by experts may not always reflect real-world clinical practice. In this study, 21 key statements from the 2nd Brazilian Consensus on Gastric Cancer were evaluated across multiple cancer reference centers. It was found that, in 10 of these statements, current clinical practice diverged from the consensus recommendations.
Some consensus statements may be revised in future editions to better reflect the realities of clinical practice in the national context. To enhance adherence to the recommendations, broad dissemination of the study results is essential, alongside the implementation of educational initiatives and institutional policies aimed at promoting guideline compliance. These measures may contribute to closing the gap between consensus recommendations and everyday clinical practice, ultimately improving patient outcomes.
Despite the preference for multimodal treatment for gastric cancer, abandonment of chemotherapy treatment as well as the need for upfront surgery in obstructed patients brings negative impacts on the treatment. The difficulty of accessing treatment in specialized centers in the Brazilian Unified National Health System (SUS) scenario is an aggravating factor.
To identify advantages, prognostic factors, complications, and neoadjuvant and adjuvant therapies survival in gastric cancer treatment in SUS setting.
The retrospective study included 81 patients with gastric adenocarcinoma who underwent treatment according to INT0116 trial (adjuvant chemoradiotherapy), CLASSIC trial (adjuvant chemotherapy), FLOT4-AIO trial (perioperative chemotherapy), and surgery with curative intention (R0 resection and D2 lymphadenectomy) in a single cancer center between 2015 and 2020. Individuals with other histological types, gastric stump, esophageal cancer, other treatment protocols, and stage Ia or IV were excluded.
Patients were grouped into FLOT4-AIO (26 patients), CLASSIC (25 patients), and INT0116 (30 patients). The average age was 61 years old. More than 60% of patients had pathological stage III. The treatment completion rate was 56%. The pathological complete response rate of the FLOT4-AIO group was 7.7%. Among the prognostic factors that impacted overall survival and disease-free survival were alcoholism, early postoperative complications, and anatomopathological status pN2 and pN3. The 3-year overall survival rate was 64.9%, with the CLASSIC subgroup having the best survival (79.8%).
The treatment strategy for gastric cancer varies according to the need for initial surgery. The CLASSIC subgroup had better overall survival and disease-free survival. The INT0116 regimen also protected against mortality, but not with statistical significance. Although FLOT4-AIO is the preferred treatment, the difficulty in carrying out neoadjuvant treatment in SUS scenario had a negative impact on the results due to the criticality of food intake and worse treatment tolerance.
Curative treatment for gastric cancer involves tumor resection, followed by transit reconstruction, with Roux-en-Y being the main technique employed. To permit food transit to the duodenum, which is absent in Roux-en-Y, double transit reconstruction has been used, whose theoretical advantages seem to surpass the previous technique.
To compare the clinical evolution of gastric cancer patients who underwent total gastrectomy with Roux-en-Y and double tract reconstruction.
A systematic review was carried out on Web of Science, Scopus, EmbasE, SciELO, Virtual Health Library, PubMed, Cochrane, and Google Scholar databases. Data were collected until June 11, 2022. Observational studies or clinical trials evaluating patients submitted to double tract (DT) and Roux-en-Y (RY) reconstructions were included. There was no temporal or language restriction. Review articles, case reports, case series, and incomplete texts were excluded. The risk of bias was calculated using the Cochrane tool designed for randomized clinical trials.
Four studies of good methodological quality were included, encompassing 209 participants. In the RY group, there was a greater reduction in food intake. In the DT group, the decrease in body mass index was less pronounced compared to preoperative values.
The double tract reconstruction had better outcomes concerning body mass index and the time until starting a light diet; however, it did not present any advantages in relation to nutritional deficits, quality of life, and post-surgical complications.
The laparoscopic gastrectomy is a relatively new procedure due mainly to the difficulties related to lymphadenectomy and reconstruction. Until the moment, technique or device to perform the esophagojejunal anastomosis by laparoscopy is still a challenge. So, a safe, cheap and quickly performing technique is desirable to be developed.
: To present technique proposed by the authors with its technical details on reconstruction with "reverse anvil".
After total gastrectomy completed intra-corporeally, the reconstruction starts with the preparation of the intra-abdominal esophagus cross-section next to the esophagogastric transition of 50%. A graduated device is prepared using Levine gastric tubes (nº. 14 and 10), 3 cm length, connected to the anvil of the circular stapler (nº. 25) with a wire thread (2-0 or 3-0) of 10 cm, which is connected to end of this device. The whole device is introduced in reverse esophagus. The esophagus is amputated and the wire is pulled after previous transfixation in the distal esophagus and the anvil positioned. The jejunal loop is sectioned 20-30 cm from duodenojejunal angle, and the anvil put in the jejunal loop and connect previously in the esophagus. Linear stapler (blue 60 mm) is used to close the opening of the jejunal loop.
The "reverse anvil" technique used by the authors facilitated the transit reestablishment after total gastrectomy, contributing to obviate reconstruction problems after total gastrectomy.
Minimally invasive surgery widely used to treat benign disorders of the digestive system, has become the focus of intense study in recent years in the field of surgical oncology. Since then, the experience with this kind of approach has grown, aiming to provide the same oncological outcomes and survival to conventional surgery. Regarding gastric cancer, surgery is still considered the only curative treatment, considering the extent of resection and lymphadenectomy performed. Conventional surgery remains the main modality performed worldwide. Notwithstanding, the role of the minimally invasive access is yet to be clarified.
To evaluate and summarize the current status of minimally invasive resection of gastric cancer.
A literature review was performed using Medline/PubMed, Cochrane Library and SciELO with the following headings: gastric cancer, minimally invasive surgery, robotic gastrectomy, laparoscopic gastrectomy, stomach cancer. The language used for the research was English.
28 articles were considered, including randomized controlled trials, meta-analyzes, prospective and retrospective cohort studies.
Minimally invasive gastrectomy may be considered as a technical option in the treatment of early gastric cancer. As for advanced cancer, recent studies have demonstrated the safety and feasibility of the laparoscopic approach. Robotic gastrectomy will probably improve outcomes obtained with laparoscopy. However, high cost is still a barrier to its use on a large scale.
The presence of lymph nodes metastasis is one of the most important prognostic indicators in gastric cancer. The micrometastases have been studied as prognostic factor in gastric cancer, which are related to decrease overall survival and increased risk of recurrence. However, their identification is limited by conventional methodology, since they can be overlooked after routine staining.
To investigate the presence of occult tumor cells using cytokeratin (CK) AE1/AE3 immunostaining in gastric cancer patients histologically lymph node negative (pN0) by H&E.
Forty patients (T1-T4N0) submitted to a potentially curative gastrectomy with D2 lymphadenectomy were evaluated. The results for metastases, micrometastases and isolated tumor cells were also associated to clinicopathological characteristics and their impact on stage grouping. Tumor deposits within lymph nodes were defined according to the tumor-node-metastases guidelines (7th TNM).
A total of 1439 lymph nodes were obtained (~36 per patient). Tumor cells were detected by immunohistochemistry in 24 lymph nodes from 12 patients (30%). Neoplasic cells were detected as a single or cluster tumor cells. Tumor (p=0.002), venous (p=0.016), lymphatic (p=0.006) and perineural invasions (p=0.04), as well as peritumoral lymphocytic response (p=0.012) were correlated to CK-positive immunostaining tumor cells in originally negative lymph nodes by H&E. The histologic stage of two patients was upstaged from stage IB to stage IIA. Four of the 28 CK-negative patients (14.3%) and three among 12 CK-positive patients (25%) had disease recurrence (p=0.65).
The CK-immunostaining is an effective method for detecting occult tumor cells in lymph nodes and may be recommended to precisely determine tumor stage. It may be useful as supplement to H&E routine to provide better pathological staging.
The carcinoembryonic antigen level in peritoneal lavage has been showing to be a reliable prognostic factor in gastric cancer.
To identify any association between carcinoembryonic antigen level in peritoneal lavage, in gastric cancer patients, with mortality, peritoneal recurrence, tumor relapse or other prognostic factors.
In total, 30 patients (22 men, 8 women; median age 66 years) with resectable gastric cancer (mainly stage III and IV) were studied. Carcinoembryonic antigen level in peritoneal lavage was detected at operation by immunocytochemical method and a level over 210 ng/g of protein was considered as positive.
There were detected 10 positive cases (33.3%) of plCEA levels. These levels were associated with mortality, RR: 2.1 (p=0.018); peritoneal recurrence, OR: 9.0 (p=0.015); and relapse or gastric cancer progression, OR: 27.0 (p=0.001).
Increased levels of plCEA fairly predicts mortality, peritoneal recurrence tumor relapse or cancer progression.
The identification of prognostic factors of gastric cancer (GC) has allowed to predict the evolution of patients.
Assess the reliability of the lymphoparietal index in the prediction of long-term survival in GC treated with curative intent.
Prospective study of the Universidad de Chile Clinical Hospital, between May 2004 and May 2012. Included all gastric cancer surgeries with curative intent. Exclusion criteria were: gastrectomies due to benign lesions, stage 4 cancers, R1 resections, palliative procedures, complete esophagogastrectomies and emergency surgeries.
A total of 284 patients were included; of the sample 65.4% were male,mean age of 64.5 years,75% were advanced cancers, 72.5% required a total gastrectomy, 30 lymph nodes harvest. Surgical morbidity and mortality were 17.2% and 1.7%. 5-year survival was 56.9%. The N+/T index could predict long-term survival in all de subgrups (p<0.0001), although had a reliable prediction in early GC (p=0.005), advanced GC (p<0.0001), signet ring cell GC (p<0.0001), proximal GC (p<0.0001) and distal GC (p<0.0001). The ROC curves N+/T index, LNR and T classification presented areas below the curve of 0.789, 0.786 and 0,790 respectively, without a significant statistical difference (p=0.96).
The N+/T index is a reliable quotient in the prognostic evaluation of gastric adenocarcinoma patients who have been resected with curative intent.
The II Brazilian Consensus on Gastric Cancer by the Brazilian Gastric Cancer Association (ABCG) was recently published. On this occasion, several experts in gastric cancer expressed their opinion before the statements presented.
To present the ABCG Guidelines (part 1) regarding the diagnosis, staging, endoscopic treatment and follow-up of gastric cancer patients.
To forge these Guidelines, the authors carried out an extensive and current review regarding each statement present in the II Consensus, using the Medline/PubMed, Cochrane Library and SciELO databases with the following descriptors: gastric cancer, staging, endoscopic treatment and follow-up. In addition, each statement was classified according to the level of evidence and degree of recommendation.
Of the 24 statements, two (8.3%) were classified with level of evidence A, 11 (45.8%) with B and 11 (45.8%) with C. As for the degree of recommendation, six (25%) statements obtained grade of recommendation 1, nine (37.5%) recommendation 2a, six (25%) 2b and three (12.5%) grade 3.
The guidelines presented here are intended to assist professionals working in the fight against gastric cancer with relevant and current information, granting them to be applied in the daily medical practice.
Since the publication of the first Brazilian Consensus on Gastric Cancer (GC) in 2012 carried out by the Brazilian Gastric Cancer Association, new concepts on diagnosis, staging, treatment and follow-up have been incorporated.
This new consensus is to promote an update to professionals working in the fight against GC and to provide guidelines for the management of patients with this condition.
Fifty-nine experts answered 67 statements regarding the diagnosis, staging, treatment and prognosis of GC with five possible alternatives: 1) fully agree; 2) partially agree; 3) undecided; 4) disagree and 5) strongly disagree A consensus was adopted when at least 80% of the sum of the answers “fully agree” and “partially agree” was reached. This article presents only the responses of the participating experts. Comments on each statement, as well as a literature review, will be presented in future publications.
Of the 67 statements, there was consensus in 50 (74%). In 10 declarations, there was 100% agreement.
The gastric cancer treatment has evolved considerably in recent years. This consensus gathers consolidated principles in the last decades, new knowledge acquired recently, as well as promising perspectives on the management of this disease.
Developed by Surya MKT