• Chemoradiotherapy
• Elderly
• Gastric cancer
• Large Type 3
• S-1
• Type 4

• Humans
• Stomach Neoplasms/therapy
• Stomach Neoplasms/pathology
• Stomach Neoplasms/mortality
• Tegafur/administration & dosage
• Tegafur/therapeutic use
• Tegafur/adverse effects
• Oxonic Acid/administration & dosage
• Oxonic Acid/therapeutic use
• Aged
• Male
• Female
• Drug Combinations
• Neoadjuvant Therapy/methods
• Aged, 80 and over
• Antimetabolites, Antineoplastic/therapeutic use
• Antimetabolites, Antineoplastic/administration & dosage
• Chemoradiotherapy/methods

While the incidence of gastric cancer (GC) in general has decreased worldwide in recent decades, the incidence of diffuse cancer historically comprising poorly cohesive cells-GC (PCC-GC) and including signet ring cell cancer is rising. Literature concerning PCC-GC is scarce and unclear, mostly due to a large variety of historically used definitions and classifications. Compared to other histological subtypes of GC, PCC-GC is nevertheless characterized by a distinct set of epidemiological, histological and clinical features which require a specific diagnostic and therapeutic approach. The aim of this review was to provide an update on the definition, classification and therapeutic strategies of PCC-GC. We focus on the updated histological definition of PCC-GC, along with its implications on future treatment strategies and study design. Also, specific considerations in the diagnostic management are discussed. Finally, the impact of some recent developments in the therapeutic management of GC in general such as the recently validated taxane-based regimens (5-Fluorouracil, leucovorin, oxaliplatin and docetaxel), the use of hyperthermic intraperitoneal chemotherapy as well as pressurized intraperitoneal aerosol chemotherapy and targeted therapy have been reviewed in depth for their relative importance for PCC-GC in particular.

• Poorly cohesive cells gastric carcinoma
• Review
• Definition
• Classification
• Therapeutic management

A multi-institutional phase II study was conducted to evaluate the efficacy and safety of preoperative docetaxel, cisplatin and S-1 therapy in marginally resectable advanced gastric cancer.

Patients with macroscopic type 4, large macroscopic type 3 and bulky lymph node metastasis received two cycles of preoperative docetaxel, cisplatin and S-1 therapy (docetaxel 40 mg/m² and cisplatin 60 mg/m² on day 1, and S-1 80 mg/m² for 14 days, every 4 weeks). The primary endpoint was the pathological response rate, with an expected value of 65%.

Thirty-one patients were enrolled in this study. The pathological response rate was 54.8%, and it was higher than the threshold value but lower than the expected rate. The R0 resection rate was 93.5%. The frequencies of grade 3–4 toxicities during docetaxel, cisplatin and S-1 therapy were 41.9% for neutropenia, 6.5% for febrile neutropenia and 32.3% for nausea/vomiting. Grade 2 and 3 surgical morbidities occurred in 23.3 and 6.7% of the patients, respectively.

Preoperative docetaxel, cisplatin and S-1 therapy was feasible in terms of chemotherapy-related toxicities and surgical morbidity, but the effect did not achieve the expected value. The association between the pathological response rate and survival will be evaluated in the final analysis of this clinical trial.

• docetaxel/cisplatin/S-1
• gastric cancer
• locally advanced cancer
• preoperative chemotherapy

• Histopathological tumor regression
• Locally advanced gastric cancer
• Neoadjuvant chemotherapy
• Overall survival
• Posttherapy nodal status

Although Borrmann type IV (B-4) gastric cancer has a higher mortality rate and presents distant metastasis easily, especially peritoneal metastasis, when diagnosed, some B-4 patients were found to have no distant metastasis by preoperative detection and underwent curative surgery, which was defined as circumscribed B-4 in our study. In this study, we focused on the circumscribed B-4 patients without distant metastasis during surgery to identify factors related to prognosis and postoperative peritoneal cavity metastasis (PPCM), which is important for selecting an appropriate therapeutic strategy.

To identify factors related to the prognosis and PPCM of B-4 patients.

A total of 117 B-4 patients who underwent gastrectomy between January 2005 and December 2012 were included in this study. Survival analysis was performed using Kaplan–Meier analysis and Cox multivariate models. Pearson correlation analyses were performed to identify the factors related to PPCM. All statistical analyses were performed using SPSS 20.0.

Lymph node status, gastrectomy type, and postoperative chemotherapy were independent prognostic factors in 117 circumscribed B-4 patients. Subtotal gastrectomy combined with chemotherapy could significantly improve the long-term survival time. Six patients who were diagnosed with pN0 and received the combination therapy had a 3-year survival rate of 100% and a median survival of 77.7 mo. Even for patients with metastatic lymph nodes (n = 13), the combination therapy also increased the 3-year overall survival rate to 57.1%. In addition, positive lymph node status was the only factor (P = 0.005) correlated with PPCM in certain B-4 patients, and chemotherapy was useful for suppressing PPCM in patients with subtotal gastrectomy but not in those with total gastrectomy.

Lymph node status is an independent prognostic factor for circumscribed B-4 patients. In addition, subtotal gastrectomy and postoperative chemotherapy could effectively improve prognosis and even suppress PPCM.

• Gastric cancer
• Circumscribed
• Borrmann type IV
• Prognosis
• Subtotal gastrectomy
• Chemotherapy

• Greater curvature
• Splenectomy
• Splenic hilar lymph node
• Therapeutic index
• Type 4 gastric cancer

• adjuvant chemotherapy
• gastric cancer
• neo-adjuvant chemotherapy

• Chemotherapy, Adjuvant
• Clinical Trials as Topic
• Humans
• Japan
• Medical Oncology
• Neoplasm Staging
• Perioperative Care/trends
• Prospective Studies
• Receptor, ErbB-2/metabolism
• Stomach Neoplasms/drug therapy
• Stomach Neoplasms/pathology
• Stomach Neoplasms/surgery

Gastric cancer, which has a high incidence and poor prognosis, remains a therapeutic challenge. Recently, neoadjuvant therapy has attracted increasing attention due to high recurrence rate and low survival rate after resection in most patients with advanced stage. Clinical trials show that neoadjuvant approaches confer a significant survival advantage for resectable locally advanced gastric cancer. The specific advantages of chemoradiotherapy compared with chemotherapy have not been clarified; optimal regimens and cycles, particularly in the preoperative setting, should be studied further; and trials aimed at determining the role of targeted and immunological therapies should be conducted.

• Chemotherapy
• Gastric cancer
• Neoadjuvant therapy
• Radiotherapy

• Apatinib
• Gastric cancer
• Neoadjuvant therapy
• Oxaliplatin
• S-1

• 5-Fluorouracil
• Capecitabine
• Docetaxel
• Gastric cancer
• NAC
• Neoadjuvant
• Oxaliplatin

Although pathological response is a common endpoint used to assess the efficacy of neoadjuvant chemotherapy (NAC) for gastric cancer, the problem of a low rate of concordance from evaluations among pathologists remains unresolved. Moreover, there is no globally accepted consensus regarding the optimal evaluation. A previous study based on a clinical trial suggested that pathological response measured using digitally captured virtual microscopic slides predicted patients’ survival well. However, the pathological concordance rate of this approach and its usefulness in clinical practice were unknown.

To investigate the prognostic utility of pathological response measured using digital microscopic slides in clinical practice.

We retrospectively evaluated pathological specimens of gastric cancer patients who underwent NAC followed by surgery and achieved R0 resection between March 2009 and May 2015. Residual tumor area and primary tumor beds were measured in one captured image slide, which contained the largest diameter of the resected specimens. We classified patients with < 10% residual tumor relative to the primary tumorous area as responders, and the rest as non-responders; we then compared overall survival (OS) and relapse-free survival (RFS) between these two groups. Next, we compared the prognostic utility of this method using conventional Japanese criteria.

Fifty-four patients were evaluated. The concordance rate between two evaluators was 96.2%. Median RFS of 25 responders and 29 non-responders was not reached (NR) vs 18.2 mo [hazard ratio (HR) = 0.35, P = 0.023], and median OS was NR vs 40.7 mo (HR = 0.3, P = 0.016), respectively. This prognostic value was statistically significant even after adjustment for age, eastern cooperative oncology group performance status, macroscopic type, reason for NAC, and T- and N-classification (HR = 0.23, P = 0.018). This result was also observed even in subgroup analyses for different macroscopic types (Borrmann type 4/non-type 4) and histological types (differentiated/undifferentiated). Moreover, the adjusted HR for OS between responders and non-responders was lower in this method than that in the conventional histological evaluation of Japanese Classification of Gastric Carcinoma criteria (0.23 vs 0.39, respectively).

The measurement of pathological response using digitally captured virtual microscopic slides may be useful in clinical practice.

• Stomach neoplasm
• Neoadjuvant therapy
• Drug therapy
• Pathology
• Prognostic factor

• Adult
• Aged
• Aged, 80 and over
• Antineoplastic Agents/therapeutic use
• Disease-Free Survival
• Female
• Gastrectomy
• Humans
• Image Interpretation, Computer-Assisted/methods
• Male
• Microscopy/methods
• Middle Aged
• Neoadjuvant Therapy
• Neoplasm Staging
• Neoplasm, Residual
• Prognosis
• Proportional Hazards Models
• Retrospective Studies
• Stomach/diagnostic imaging
• Stomach/pathology
• Stomach Neoplasms/mortality
• Stomach Neoplasms/pathology
• Stomach Neoplasms/therapy
• Treatment Outcome
• Young Adult

• Large type 3
• Linitis plastica
• Neoadjuvant chemotherapy

• Gastric cancer
• conversion therapy
• hyperthermic intraperitoneal chemotherapy
• metastasectomy
• metastasis

• Gastric cancer
• Preoperative chemoradiotherapy
• Preoperative chemotherapy

• adenocarcinoma
• autonomic pathways
• chemotherapy, adjuvant
• drug therapy
• esophagogastric junction
• reconstructive surgical procedures

• Adenocarcinoma/pathology
• Adenocarcinoma/therapy
• Aged
• Anastomosis, Surgical/instrumentation
• Chemotherapy, Adjuvant
• Esophageal Neoplasms/pathology
• Esophageal Neoplasms/therapy
• Esophagogastric Junction/pathology
• Esophagogastric Junction/surgery
• Humans
• Jejunostomy
• Lymph Node Excision
• Male
• Middle Aged

• chemotherapy
• co-operative group
• gastric cancer

• Antibodies, Monoclonal/therapeutic use
• Antibodies, Monoclonal, Humanized
• Antineoplastic Combined Chemotherapy Protocols/therapeutic use
• Chemotherapy, Adjuvant
• Clinical Trials as Topic
• Combined Modality Therapy
• Humans
• Stomach Neoplasms/drug therapy
• Trastuzumab/therapeutic use
• Ramucirumab

Gastric cancer (GC) remains one of the most common tumors in China. Most patients with GC in China are already in a locally advanced stage at the time of diagnosis. Neoadjuvant therapy has attracted increasing attention. Clinical literature and meta-analyses show that neoadjuvant therapy results in a significant survival benefit for resectable locally advanced GC, and preoperative chemoradiotherapy also should be a standard treatment for advanced GC vs surgery alone. The optimal regimens of neoadjuvant therapy and comparisons between preoperative chemotherapy and chemoradiotherapy still need to be studied further.

• Advanced gastric cancer
• Gastric cancer
• Neoadjuvant radiotherapy
• Neoadjuvant chemotherapy
• Neoadjuvant chemoradiotherapy

Scirrhous gastric cancer (SGC) is highly invasive and metastatic because of its interactions with stromal cells, such as fibroblasts and macrophages, and extracellular matrix, leading to a higher incidence of peritoneal metastasis (PM) than other gastric cancers (GCs). Taxane-based intraperitoneal chemotherapy (IPC) is a promising therapy for PM. We retrospectively analyzed outcomes of multidisciplinary therapies that included IPC for SGC.

Of 1,679 GC patients treated between 1990 and 2012, we analyzed 119 patients who underwent multidisciplinary therapy for SGC. Patients without PM received gastrectomy with lymphadenectomy and resection of involved adjacent organs followed by intraoperative IPC using cisplatin. Patients with PM received chemotherapy using fluorouracil, with or without methotrexate plus IPC using cisplatin before 2000, and S-1 plus IPC using paclitaxel or docetaxel since 2000.

Of the 119 patients, 73 (61%) had PM and 63 (53%) had positive peritoneal lavage cytology. Of the 89 gastrectomy patients, 30 (34%) had macroscopic residual tumors (R2). Of the patients treated since 2000, 66 (100%) received S-1 plus taxanes and 44 patients (67%) received taxane-based IPC. Median survival time was significantly longer in the post-2000 group (22.8 months) than in the pre-2000 group (9.5 months). In univariate analysis, lavage cytology, PM, taxane-based IPC, gastrectomy, and R2 resection were significant prognostic factors. However, only R2 resection was an independent prognostic factor in multivariate analysis (hazard ratio: 5.53, 95% CI: 2.05–14.93).

As use of taxane-based IPC is not an independent prognostic factor, new multidisciplinary therapies are necessary to avoid R2 resections.

• intraperitoneal chemotherapy
• peritoneal metastasis
• taxanes

The purpose of this study was to evaluate the relationship between extracapsular lymph node spread (ECS) and clinicopathology and its influence on the prognosis in patients with Borrmann type IV gastric cancer. Between 2002 and 2014, clinical data were reviewed from 486 patients with Borrmann type IV gastric cancer who underwent curative resection. Of the 486 patients, lymph node metastasis was found in 456. ECS was detected in 213 (46.7%) patients with lymph node metastasis. A positive lymph node with ECS was significantly correlated with the N category, lymphatic/venous invasion, tumor location, and TNM stage. For the whole patients, the mean OS was 34.7 months, and the 5-year OS rate was 15.5%. The 5-year OS rate of node-negative patients was 48%, for node-positive patients without ECS 18.7%, and for node-positive patients with ECS 5.7% (P = 0.000). In a multivariate analysis, adjusted for tumor location, lymphatic/venous invasion, body mass index (BMI), and TNM stages, ECS remained an independent prognostic factor. For patients with the same N category and TNM stage, those with ECS still had a worse survival rate. Recurrent sites were confirmed in 367 patients. The most frequent recurrent site was the peritoneum. There was a significant difference between ECS+ (N = 150) and ECS- (N = 142) patients (P = 0.008). Our results suggested that ECS was an independent prognostic value for Borrmann type IV gastric cancer patients with curative resection and a subgroup indicated a significantly worse long-term survival for patients with the same N or TNM stages. ECS+ was an adverse factor for peritoneal metastasis.

• Borrmann type IV gastric cancer
• curative resection
• extracapsular lymph node spread
• metastasis
• prognosis

• Adjuvant chemotherapy
• D2 dissection
• Esophagogastric junctional cancer
• Gastric cancer
• Multidisciplinary treatment
• Neoadjuvant chemotherapy

• Gastric cancer
• Metastasis
• Neoadjuvant chemotherapy
• Scirrhous

• Algorithms
• Clinical Trials as Topic/standards
• Combined Modality Therapy
• Humans
• Japan
• Stomach Neoplasms/drug therapy
• Stomach Neoplasms/surgery
• Stomach Neoplasms/therapy
• Time Factors

In the last 20 years, several clinical trials on neoadjuvant chemotherapy and chemo-radiotherapy as a therapeutic approach for locally advanced gastric cancer have been performed. Even if more data are necessary to define the roles of these approaches, the results of preoperative treatments in the combined treatment of gastric adenocarcinoma are encouraging because this approach has led to a higher rate of curative surgical resection. Owing to the results of most recent randomized phase III studies, neoadjuvant chemotherapy for locally advanced resectable gastric cancer has satisfied the determination of level I evidence. Remaining concerns pertain to the choice of the optimal therapy regimen, strict patient selection by accurate pre-operative staging, standardization of surgical procedures, and valid criteria for response evaluation. New well-designed trials will be necessary to find the best therapeutic approach in pre-operative settings and the best way to combine old-generation chemotherapeutic drugs with new-generation molecules.

• Gastric Cancer
• Neo-adjuvant treatment
• Chemotherapy
• Radiotherapy

• MDCT
• enlarged lymph node
• gastric cancer
• total diameter

AIM: To investigate the efficacy of neoadjuvant chemoradiotherapy (NACRT) for resectability of locally advanced gastric cancer (LAGC).

METHODS: Between November 2007 and January 2014, 29 patients with LAGC (clinically T3 with distal esophagus invasion/T4 or bulky regional node metastasis) that were treated with NACRT followed by D2 gastrectomy were included in this study. Resectability was evaluated with radiologic and endoscopic exams before and after NACRT. Using three-dimensional conformal radiotherapy, patients received 45 Gy, with a daily dose of 1.8 Gy. The entire tumor extent and the regional metastatic lymph nodes were included in the gross tumor volume. Patients presenting with a resectable tumor after NACRT received a total or subtotal gastrectomy with D2 dissection. The pathologic tumor response was evaluated using Japanese Gastric Cancer Association histologic evaluation criteria. Postoperative morbidity was evaluated using the National Cancer Institute-Common Terminology Criteria for Adverse Events version 4.0. Overall survival (OS) and progression-free survival (PFS) rates were estimated using a Kaplan-Meier analysis and compared using the log-rank test.

RESULTS: All patients were assessed as unresectable cases. Twenty-four patients (24/29; 82.8%) showed LAGC on positron emission tomography-computed tomography (CT) and contrast-enhanced CT, whereas four patients (4/29; 13.8%) with vague invasion or abutment to an adjacent organ underwent diagnostic laparoscopy. One patient (1/29; 3.4%), initially assessed as a resectable case, underwent an “open and closure” after the tumor was found to be unresectable. Abutment to an adjacent organ (34.5%) was the most common reason for NACRT. The clinical response rate one month after NACRT was 44.8%. After NACRT, 69% (20/29) of patients had a resectable tumor. Of the 20 patients with a resectable tumor, 18 patients (62.1%) underwent a D2 gastrectomy. The R0 resection rate was 94.4% and two patients (2/18; 11.1%) showed a complete response. The median follow-up duration was 13.5 mo. The one-year OS and PFS rates were 72.4 and 48.9%, respectively. The one-year OS, PFS, local failure-free survival, and distant metastasis-free survival were higher in patients with a resectable tumor after NACRT (P < 0.001, P < 0.001, P < 0.001, and P = 0.078, respectively). No grade 3-4 late treatment-related toxicities or postoperative mortalities were observed.

CONCLUSION: NACRT with D2 gastrectomy showed a high rate of R0 resection and promising local control, which may increase the R0 resection opportunity resulting in survival benefit.

• Advanced gastric cancer
• D2 gastrectomy
• Neoadjuvant chemoradiotherapy
• Combined modality therapy
• Treatment outcome

• Adult
• Aged
• Chemoradiotherapy/adverse effects
• Chemoradiotherapy/methods
• Chemoradiotherapy/mortality
• Disease Progression
• Disease-Free Survival
• Female
• Gastrectomy/methods
• Humans
• Kaplan-Meier Estimate
• Lymphatic Metastasis
• Male
• Middle Aged
• Multimodal Imaging
• Neoadjuvant Therapy/adverse effects
• Neoadjuvant Therapy/methods
• Neoadjuvant Therapy/mortality
• Neoplasm Invasiveness
• Neoplasm Recurrence, Local
• Positron-Emission Tomography
• Radiation Dosage
• Radiotherapy, Conformal/adverse effects
• Radiotherapy, Conformal/mortality
• Retrospective Studies
• Risk Factors
• Stomach Neoplasms/drug therapy
• Stomach Neoplasms/mortality
• Stomach Neoplasms/pathology
• Stomach Neoplasms/surgery
• Time Factors
• Tomography, X-Ray Computed
• Treatment Outcome
• Tumor Burden

After a long history of Dark Age of adjuvant chemotherapy for gastric cancer, definite evidences of survival benefit from adjuvant treatment have been reported since 2000s. These survival benefits are likely attributed to something new approach different from pervious studies. In 2001, South West Oncology Group INT0116 trial yielded survival benefit in curatively resected gastric cancer patients with postoperative chemoradiotherapy [5-fluorouracil (5-FU) + Leucovorin + radiotherapy], followed by positive result by MAGIC Trial, employing peri-operative(pre- and postoperative chemotherapy with Epirubicin, cisplatin (CDDP), 5-fluorouracil (ECF) regimen in patients with curative resection. A novel drug [S1: ACTS-GC (Adjuvant chemotherapy trial of TS-1 for gastric cancer) in 2007], or new drug combination chemotherapys [CDDP + 5-FU: FNCLCC/FFCD (Federation Nationale des Centres de Lutte contre le cancer/Federation Francophone de Cancerologie Digestive) in 2011, Capecitabine + Oxaliplatin: CLASSIC in 2012] also produced positive results in terms of improved prognosis. Neoadjuvant or perioperative chemotherapy, novel anti-cancer drugs, and chemoradiotherapy might be the key words to develop further improvement in the adjuvant treatment of resectable gastric cancer. Moreover, it is not new but still true to stress the importance of D2 surgery as the baseline treatment in order to minimize the amount of residual tumor after surgery.

• Resected gastric cancer
• Phase III clinical trial
• Adjuvant and neo-adjuvant therapy
• Chemoradiotherapy
• Review

• Antineoplastic Combined Chemotherapy Protocols/therapeutic use
• Chemoradiotherapy, Adjuvant
• Chemotherapy, Adjuvant
• Gastrectomy
• Humans
• Neoadjuvant Therapy
• Neoplasm, Residual
• Radiation Dosage
• Stomach Neoplasms/pathology
• Stomach Neoplasms/therapy
• Treatment Outcome

• Adenocarcinoma/drug therapy
• Adenocarcinoma/mortality
• Adenocarcinoma/surgery
• Chemotherapy, Adjuvant
• Disease-Free Survival
• Humans
• Neoadjuvant Therapy
• Randomized Controlled Trials as Topic
• Stomach Neoplasms/drug therapy
• Stomach Neoplasms/mortality
• Stomach Neoplasms/surgery
• Survival Rate
• Treatment Outcome

• Adenocarcinoma/drug therapy
• Adenocarcinoma/mortality
• Adenocarcinoma/surgery
• Chemotherapy, Adjuvant
• Disease-Free Survival
• Humans
• Neoadjuvant Therapy
• Randomized Controlled Trials as Topic
• Stomach Neoplasms/drug therapy
• Stomach Neoplasms/mortality
• Stomach Neoplasms/surgery
• Survival Rate
• Treatment Outcome

Indications for laparoscopic gastrectomy (LG) for early stomach cancer have spread worldwide and evaluation of short-term outcomes has been favorable. The present study aimed to evaluate both technical feasibility and safety of LG and short-and long-term outcomes after LG.

The study group comprised 231 patients who underwent LG during the period from August 2001 through December 2011 at Gifu University School of Medicine.

Concomitant resection of other organs was performed in 16 (6.9 %) of the 231 patients, and conversion to open surgery was performed in 5 (2.2 %) patients. The final clinical stage of the patients, according to the Union for International Cancer Control classification, was stage IA in 183 (79.0 %), stage IB in 26 (11.3 %), stage IIA in 9 (2.6 %), stage IIB in 6 (2.6 %), stage IIIA in 5 (2.2 %), and stage IIIB in 2 (0.9 %) patients. Average values of total blood loss and operation time were 133.7 ± 129.0 ml and 328.1 ± 70.1 min, respectively. Postoperative complications were detected in 29 patients (12.6 %), and one patient died. According to the Clavien–Dindo classification of surgical complications, the rate of severe complications of grade ≥3a was 6.1 % and that of grade ≥3b was 1.3 %. There were no significant differences in complications in relation to clinicopathological or operative procedures. Cancer recurrence was detected in 2 (0.9 %) patients. In the patient with peritoneal dissemination, tumor size and macroscopic type were critical. Five-year overall survival rates were 99.3 % for stage IA, 95.2 % for stage IB, and 50.0 % for stage IIB patients. One recurrence each was detected for stages IA and IIB cancers.

The present study showed LG to have a safe postoperative course and to benefit oncologic outcomes.

• Antineoplastic Combined Chemotherapy Protocols/therapeutic use
• Cisplatin/administration & dosage
• Combined Modality Therapy
• Disease-Free Survival
• Humans
• Postoperative Complications
• Silicates/administration & dosage
• Stomach Neoplasms/drug therapy
• Stomach Neoplasms/radiotherapy
• Stomach Neoplasms/therapy
• Titanium/administration & dosage
• Treatment Outcome

Patients with type 4 gastric cancer and peritoneal metastasis respond better to chemotherapy than surgery. In particular, patients without gastric stenosis who can consume a meal usually experience better quality of life (QOL). However, some patients with unsuccessful chemotherapy are unable to consume a meal because of gastric stenosis and obstruction. These patients ultimately require salvage surgery to enable them to consume food normally. We evaluated the outcomes of salvage total gastrectomy after chemotherapy in four patients with gastric stenosis. We determined clinical outcomes of four patients who underwent total gastrectomy as salvage surgery. Outcomes were time from chemotherapy to death and QOL, which was assessed using the Support Team Assessment Schedule-Japanese version (STAS-J). Three of the patients received combination chemotherapy [tegafur, gimestat and otastat potassium (TS-1); cisplatin]. Two of these patients underwent salvage chemotherapy after 12 and 4 mo of chemotherapy. Following surgery, they could consume food adequately and their STAS-J scores improved, so their treatments were continued. The third patient underwent salvage surgery after 7 mo of chemotherapy. This patient was unable to consume food adequately after surgery and developed surgical complications. His clinical outcomes at 3 mo were very poor. The fourth patient received combination chemotherapy (TS-1 and irinotecan hydrochloride) for 6 mo and then underwent received salvage surgery. After surgery, he could consume food adequately and his STAS-J score improved, so his treatment was continued. After the surgery, he enjoyed his life for 16 mo. Of four patients who received salvage total gastrectomy after unsuccessful chemotherapy, the QOL improved in three patients, but not in the other patient. Salvage surgery improves QOL in most patients, but some patients develop surgical complications that prevent improvements in QOL. If salvage surgery is indicated, the surgeon and/or oncologist must provide the patient with a clear explanation of the purpose of surgery, as well as the possible risks and benefits to allow the patient to reach an informed decision on whether to consent to the procedure.

• Type 4 gastric cancer
• Quality of life
• Salvage surgery
• Support Team Assessment Schedule-Japanese version
• Palliative care
• Systemic chemotherapy
• Gastric stenosis

Neoadjuvant chemotherapy (NAC) has drawn more attention to the treatment of locally advanced gastric cancer (AGC) in the current multidisciplinary treatment model. EORTC trial 40954 has recently reported that NAC plus surgery without postoperative adjuvant chemotherapy could not benefit the locally AGC patients in their overall survival. We performed a meta-analysis of 10 studies including 1518 gastric cancer patients. Stratified subgroups were NAC plus surgery and NAC plus both surgery and adjuvant chemotherapy (AC), while control was surgery alone. The results showed that NAC plus surgery did not benefit the patients with locally AGC in their overall survival [odds ratio (OR) = 1.20, 95% CI 0.80-1.80, P = 0.37] and the number needed to treat (NNT) was 74. However, the NAC plus both surgery and AC had a slight overall survival benefit (OR = 1.33, 95% CI 1.03-1.71, P = 0.03) and NNT was 14, which is superior to the NAC plus surgery. Therefore, we recommend that combined NAC and AC should be used to improve the overall survival of the locally AGC patients.

• Gastric cancer
• Adjuvant chemotherapy
• Neoadjuvant chemotherapy
• Surgery
• Survival