1. USF1 202 G/A Polymorphism and Circulating USF1/USF2 Levels as Biomarkers of Gastric Cancer Susceptibility
Authors: Ghizlane Bounder¹, Mohamed Reda Jouimyi¹, Imane Essaidi¹, Ilhame Elyounsi⁴, Hasna Boura¹, Valérie Michel², Wafa Badre⁴, Eliette Touati³, Fatima Maachi¹
Affiliation: ¹ Helicobacter Pylori and Gastric Pathologies Laboratory, Institut Pasteur du Maroc, Casablanca, Morocco ² Faculty of Medicine, University of Tours, Tours, France ³ Équipe DMic01-Infection, Génotoxicité et Cancer, département de Microbiologie, Centre National de la Recherche Scientifique (CNRS) Unité Mixte de Recherche (UMR) 6047, Institut Pasteur, Université Paris Cité, 75015 Paris, France ⁴ Gast
Introduction: Gastric cancer remains one of the most aggressive neoplasms worldwide, often associated with a bad prognosis. Identifying genetic and serological biomarkers is essential for early detection and risk stratification. Upstream Stimulatory Factors USF1 and USF2 are pleiotropic transcription factors implicated in cellular metabolism, immune regulation, and tumor suppression, with altered expression patterns reported in gastric carcinogenesis.
Objective: Our case-control study aimed to investigate the association between the USF1-202 G/A promoter polymorphism, serum concentrations of USF1 and USF2, and gastric cancer risk in Helicobacter pylori-infected individuals with chronic gastritis, precancerous gastric lesions, gastric cancer, and healthy controls.
Methodology: Genotyping was performed using Sanger sequencing, and serum protein levels were measured by ELISA.
Results: The results showed that the A allele was significantly associated with an increased risk of gastric cancer, and individuals carrying GA or AA genotypes exhibited a markedly higher susceptibility compared with GG homozygotes. The G to A transition was associated with substantially reduced circulating USF1 levels, with the lowest concentrations observed in patients with gastric cancer. This reduction was approximately 2.3 and twofold in the AA and GA genotypes, respectively, compared to GG carriers, suggesting functional consequences of the polymorphism on USF1 expression. Changes in serum USF2 levels were also detected across disease stages, indicating a broader dysregulation of the USF transcription factor network. This imbalance may contribute to alterations in metabolic and inflammatory pathways within the tumor microenvironment.
Conclusions: These findings identify USF1 202 G/A polymorphism and serum USF1/USF2 concentrations as promising biomarkers for gastric cancer detection and prevention strategies.
Keywords: Gastric cancer · Genetic polymorphism · Genetic risk factor · Biomarkers · Serum levels
2. Unveiling the prevalence of Helicobacter pylori CagA and VacA virulence markers in Moroccan children and adolescents
Authors: Hasna Boura, fatimezzahra kheir,meryama lasky,bounder ghizlane, noureddine harich and aicha baalala .
Affiliation: Institu Pasteur of Morocco
Introduction: Purpose Heterogeneity in the vacA and cagA pathogenicity factors of Helicobacter pylori (H.pylori) has been correlated with the progression and the severity of gastrointestinal disease in adults; however, data regarding these markers in the pediatric population remain limited.
Objective: The objective of this research was to assess the distribution of the vacA and cagA virulence markers in symptomatic Moroccan children and adolescents, as well as their association with histologic and endoscopic findings
Methodology: Gastric tissue samples were retrieved from two hundred children and adolescents referred for upper gastrointestinal endoscopy. Conventional PCR was employed to detect H. pylori infection and the presence of the cagA gene, whereas multiplex-PCR was used to characterize the vacA allelic variants (s and m alleles).
Results: From the 200 children and adolescents involved in this research, 84,5% tested positive for H. pylori. Among these,32% carried the cagA gene, and vacA was identified in all H. pylori strains. The most prevalent genotype combination was the vacA s2/m2 genotype, affecting 67.5% of the infected patients, followed by s1/m2 (16%), s1/m1 (14.7%), with the vacA s2/m1 being the rarest genotype (1.8%). Gastric nodularity was frequently observed in patients harboring cagA-positive strains. A meaningful association was noted between H. pylori colonisation density and the vacA s1 and m1 genotypes.Histological findings showed no significant variation according to vacA and cagA genotypes.
Conclusions: Our results showed that H. pylori strains harboring the vacA s2 m2 and cagA-negative genotypes were the most frequently detected among children and adolescents in our country. Larger-scale studies are needed to investigate the potential clinical relevance of other virulence markers in the progression of this infection among pediatric patients in our country.
Keywords: Hélicobacter pylori, Cag, Vac, virulence markers, pediatric patients.
3. Treatment of patients with gastric cancer complicated by bleeding
Authors: Severtsev A.N., Ovchinnikov S.V., Mongush Ch.M., Aliev N.S., Glebov K.G., Jurakulov S.R., Frecautanu D., Shapovalov D.A., Korotaev A.V.
Affiliation: Pirogov Russian National Research Medical University, Moscow, Russia
Introduction: Treatment of patients with gastric cancer with bleeding remains an unresolved issue (high mortality, frequent relapses, and failure to administer antitumor therapy). The lack of standardized treatment algorithms makes it crucial to study their effectiveness.
Objective: The aim of this study was to identify treatment strategies for patients with gastric cancer complicated by bleeding.
Methodology: Single-center study (January 2020 – December 2025). A total of 123 patients with gastric malignancy complicated by bleeding were included; age ≥18 years. Patients were divided into three groups: transcatheter arterial embolization (TAE) — n=72; conservative/endoscopic treatment — n=43; and surgery after application of all hemostatic methods — n=8. All patients underwent hemodynamic assessment, laboratory tests, early endoscopy, and, if indicated, selective angiography followed by embolization.
Results: The technical success of local hemostasis was high.Clinical results: In the TAE group (n=72), in-hospital mortality was 10 patients (13.9%); 13 (21% of 62 patients) died within 30 days after discharge. In the conservative/endoscopic treatment group (n=43), in-hospital mortality was 5 (11.6%); after discharge, 7 (19.5% of 36 patients). In the surgical group (n=8), in-hospital mortality was 0; after discharge, 1 (16.7% of 7). The number of deaths associated with bleeding was significantly higher in the conservative treatment group. Recurrent bleeding within a month after discharge: TAE — 8/72 (11.1%); conservative — 10/43 (23.3%); operated — 0/8 (0%). During TAE, the left gastric artery was predominantly embolized (n=58). Microemboli (n=37), coils (n=25), and combinations (n=10) were used during TAE.
Conclusions:
- Endoscopic treatment is appropriate as a primary measure for hemostasis, but requires preparedness for subsequent treatments in case of recurrence.
- TAE is recommended if endoscopic treatment is ineffective, there is massive bleeding, tumor size >2 cm, and significant comorbidity; in the absence of visible extravasation, empirical embolization is acceptable.
- Surgical treatment should be planned only after the patient’s condition has stabilized and optimized; patients should not be discharged after TAE (Surgery within the same hospitalization).
Keywords: gastric cancer; bleeding; transcatheter arterial embolization;
4. Simultaneous Minimally Invasive Management of Synchronous Gastric GIST and Stage III Cecal Adenocarcinoma: A Multidisciplinary Decision-Making Challenge
Authors: Thita Intralawan, Nisa Potsoonthorn, Natcha Boontanagon, Natcha Wipaskatanyu
Affiliation: Department of Surgery, Ratchaburi Hospital, Ministry of Public Health, Thailand
Introduction: Synchronous tumors involving the stomach and colon are uncommon and are often incidentally detected during evaluation for unrelated symptoms. Although management strategies for each tumor entity are well established, there is no standardized approach for the management of synchronous gastric tumors and colorectal adenocarcinoma, posing challenges in determining optimal treatment sequencing and surgical strategy.
Objective: To present a case of synchronous gastric gastrointestinal stromal tumor (GIST) and stage III cecal adenocarcinoma, and to highlight the multidisciplinary decision-making process and feasibility of a simultaneous minimally invasive surgical approach.
Methodology: A 71-year-old male presented with right lower quadrant abdominal pain, initially suspected as acute appendicitis. Computed tomography revealed cecal wall thickening and an incidental gastric mass.
|Further evaluation with esophagogastroduodenoscopy (EGD) and endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) confirmed a gastric GIST (CD117+, DOG1+), while colonoscopy identified a cecal mass suspicious for malignancy.
Following multidisciplinary discussion, the patient underwent simultaneous laparoscopic wedge resection of the gastric tumor and laparoscopic-assisted right hemicolectomy with ileocolic anastomosis.
Results: The postoperative course was uneventful, with early return of bowel function and good oral intake.
Histopathology demonstrated a well-differentiated adenocarcinoma of the cecum, pT3N1a (1/23 lymph nodes), Stage IIIB, with negative margins, and a gastric GIST measuring 8 cm, spindle cell type, with a low mitotic rate (<5/5 mm2) and negative margins.
The patient was referred for adjuvant chemotherapy for colon cancer, while no adjuvant therapy was indicated for the GIST based on risk assessment.
Conclusions: Synchronous gastric GIST and colorectal adenocarcinoma is rare and presents a complex therapeutic dilemma. Simultaneous minimally invasive resection is feasible and safe in selected patients, avoiding the morbidity of staged procedures and extensive incisions.|
Management should be individualized through a multidisciplinary approach, as the biological association between these tumors remains unclear, and treatment strategies must be tailored according to the behavior of each tumor type.
Keywords: Synchronous tumor; Gastric GIST; Colorectal cancer; Laparoscopic surgery; Multidisciplinary management
5. Radical Surgery versus Non-Surgical Management After Successful Conversion Therapy for Gastric Cancer with Peritoneal Metastasis: A Phase III Prospective Multicenter Randomized Controlled Trial (ALANO)
Authors: Hua Huang
Affiliation: Department of Gastric Surgery, Fudan University Shanghai Cancer Center, No. 270 Dong’an Road, Shanghai 200032, China.
Introduction: Gastric cancer (GC) complicated by peritoneal metastasis (PM) carries a dismal prognosis, with a historical median overall survival (OS) of less than one year. The emergence of conversion therapy, integrating neoadjuvant intraperitoneal and systemic chemotherapy (NIPS) with immunotherapy, has enabled a subset of patients to achieve „successful conversion”—the complete macroscopic resolution of peritoneal disease. However, a significant clinical equipoise exists regarding the optimal management for these responders. It remains unknown whether radical gastrectomy offers a survival advantage over continued standard-of-care (SOC) systemic therapy. The ALANO trial attempts to answer this clinical scientific question.
Objective: To determine whether radical gastrectomy provides a survival advantage over continued standard-of-care (SOC) systemic therapy for patients with gastric cancer and peritoneal metastasis (GCPM) who have achieved a complete macroscopic resolution of peritoneal disease („successful conversion”) after conversion therapy. The ALANO trial aims to provide high-level, evidence-based guidance for this clinical scenario and potentially establish a new standard of care.
Methodology: ALANO is a prospective, multicenter, open-label, phase III randomized controlled non-inferiority trial involving 31 high-volume centers across China. Eligible patients are aged 18–70 with histologically confirmed GC and laparoscopically staged PM (Peritoneal Cancer Index [PCI] ≤ 20). The study employs a two-stage enrollment process: following initial staging, patients undergo 6–8 cycles of conversion therapy. Those achieving a favorable clinical response subsequently undergo a second-look laparoscopy for definitive assessment. Patients confirmed to have achieved complete peritoneal response (CY0P0 status) are then randomized (1:1) to either the Surgery Group (radical gastrectomy with D0–D2 lymphadenectomy, followed by postoperative adjuvant therapy) or the SOC Group (continuation of systemic therapy or transition to maintenance treatment). The primary endpoint is OS, evaluated with a non-inferiority margin defined by a Hazard Ratio (HR) of 1.30.
Results: The primary outcome to be measured is overall survival (OS). Key secondary outcomes include quality of life (QoL), progression-free survival (PFS), pathological complete response (pCR) rate, the incidence of major surgical complications, and a comprehensive economic analysis.
Conclusions: By directly comparing an aggressive surgical strategy against a modern systemic-based approach, the findings from the ALANO trial are expected to redefine the treatment algorithm for patients with converted GCPM. The trial has the potential to establish a new standard of care that optimally balances oncological outcomes with patient quality of life.
Keywords: Gastric cancer, Peritoneal metastasis, Conversion therapy, Radical surgery, Randomized controlled trial, Non-inferiority, Quality of life.
6. Is omentectomy necessary in gastric cancer surgery? Long-term outcomes from a 20-year omentum-preserving cohort
Authors: Troncoso Magdalena, Iria; Busto Hermida, Leticia; Salgado Álvarez, Rocío; Pallarés Pereira, Alejandra; Parada Pérez-Mancebo, Álvaro; Toscano Novella, Alberto; Climent Aira, Antonio
Affiliation: Hospital Ribera Povisa
Introduction: Omentectomy has traditionally been considered a standard component of surgery for gastric adenocarcinoma (GA) because the greater omentum may contain occult tumor deposits or micrometastases. Nevertheless, its real oncological benefit remains uncertain, and recent evidence suggests that omentum preservation could reduce surgical aggressiveness and postoperative morbidity without compromising survival or recurrence outcomes. Despite growing interest in less extensive surgical approaches, there is still no clear international consensus or high-level evidence supporting the routine use of omentectomy during gastrectomy for GA.
Objective: To evaluate whether omentum preservation in patients undergoing curative-intent gastrectomy for GA compromises oncological outcomes and/or reduces postoperative morbidity and mortality.
Methodology: A retrospective descriptive analysis of an initial cohort of 400 patients undergoing surgery for GA between March 2003 and March 2026. After applying exclusion criteria (palliative intent, incomplete medical records, omentectomy, and <12 months follow-up), 199 patients undergoing omentum-preserving gastrectomy were included. Demographic, surgical, and postoperative variables were collected, including complications, overall survival (OS), and disease-free survival (DFS).
Results: Mean age was 70 years (61.8% male), with a mean BMI of 27.1. Most patients were ASA II (43.2%) or ASA III (45.2%), with a mean Charlson Comorbidity Index of 4.9. Neoadjuvant therapy was administered in 18.6% of patients and prehabilitation in 21.6%. Tumors were predominantly located in the antrum (47.7%) and body (35.2%), with intestinal-type histology in 60.3%. Laparoscopic surgery was performed in 93.9%, with subtotal gastrectomy in 55.3% and total gastrectomy in 43.2%, including D2 lymphadenectomy in 67.8% and Roux-en-Y reconstruction in 85.4%.Pathological staging was in situ in 8.5%, stage I in 37.2%, stage II in 32.1%, and stage III in 22.1%. Postoperatively, contrast swallow study with Gastrografin was performed in 71.9% of patients (85.3% normal). Anastomotic leak rate was 17.6%, and early reoperation rate was 11.6%. Overall, 45.7% of patients developed postoperative complications: 38.1% grade I–II and 53.3% grade III–IV according to Clavien–Dindo classification, with a Comprehensive Complication Index (CCI) of 20.5. Mean length of stay was 14.7 days (median 7 days). Readmission rate was 21.6%, with 44.2% requiring reoperation. Adjuvant treatment was administered in 33.7% of patients, with an overall recurrence rate of 28.6%.Mean OS was 2422 days and DFS 2377 days. Kaplan–Meier estimated OS was 71.4% at 3 years and 64.1% at 5 years, with cumulative tumor-related mortality of 23.5% and 29.1%, respectively. DFS was 65.8% at 3 years and 60.6% at 5 years, with cumulative event rates of 23.0% and 25.6%, respectively.According to surgical type, subtotal gastrectomy showed better outcomes than total gastrectomy, with higher OS (81.4% vs 59.1% at 3 years; 72.6% vs 53.3% at 5 years) and improved DFS (75.6% vs 53.4% at 3 years; 69.2% vs 49.7% at 5 years), as well as lower cumulative recurrence and tumor-related mortality. Advanced tumor invasion (T3–T4) was independently associated with worse OS and DFS, with higher risk of recurrence and mortality.
Conclusions: The results of our cohort, in line with systematic reviews and ongoing clinical trials, suggest that omentum preservation during gastrectomy for GA is oncologically safe, without increasing recurrence risk or reducing survival, and may be associated with lower surgical aggressiveness and improved postoperative recovery.
Keywords: Gastric adenocarcinoma; Gastrectomy; Omentectomy; Omentum preservation; Gastric cancer surgery; Oncological outcomes; Minimally invasive surgery; Laparoscopic gastrectomy; D2 lymphadenectomy
7. Curative-intent treatment for distal gastric cancer with gastric outlet obstruction: Management pathways and clinical outcomes from a Swedish multicenter cohort
Authors: Adam Zeyara, Léonie Scarfone, Martina Hermez Chole, Dan Falkenback, Bobby Tingstedt, Jan Johansson, Ioannis Rouvelas
Affiliation: Department of Surgery, Skåne University Hospital in Lund, Sweden
Introduction: Distal gastric cancer with gastric outlet obstruction (GOO) poses challenges to multimodal treatment. The optimal management strategy in patients undergoing curative-intent treatment remains unclear.
Objective: This study aimed to characterize real-world management pathways and outcomes in patients with distal gastric cancer presenting with clinically significant GOO.
Methodology: All consecutive patients undergoing curative-intent resection for distal gastric adenocarcinoma with GOO between 2006 and 2024 at two Swedish tertiary centers were identified from national registry and institutional databases with chart validation. Patients were categorized according to treatment strategy: neoadjuvant chemotherapy or up-front surgery. Primary outcome was overall survival. Survival was analyzed using Kaplan–Meier estimates and multivariable Cox regression adjusting for age, ASA class, clinical T stage and nodal status.
Results: A total of 103 patients were included; 36 (35.0%) received neoadjuvant chemotherapy and 67 (65.0%) underwent up-front surgery. Patients receiving neoadjuvant therapy were younger (median 63.7 vs 77 years, p<0.001) and more frequently had cT3–4 and cN+ disease (p<0.001). Most patients completed planned neoadjuvant treatment. R1 resection rates were high and comparable between groups (30.6% vs 28.4%, p=0.75). Median overall survival was 19.6 months after neoadjuvant therapy and 19.2 months after up-front surgery (log-rank p=0.38). On multivariable analysis, treatment strategy was not independently associated with overall survival (HR 0.86, 95% CI 0.47–1.57; p=0.63).
Conclusions: GOO in distal gastric cancer should not be considered an absolute contraindication to neoadjuvant therapy when adequate nutritional and supportive strategies are employed. However, feasibility does not equal justification – in the absence of a survival benefit and in the context of increased severe postoperative complications, treatment decisions should be individualized through careful multidisciplinary assessment until better powered prospective studies are performed.
Keywords: Gastric outlet obstruction, curative-intent gastrectomy, neoadjuvant chemotherapy, nutritional support
8. Pattern of lymph node spread in gastric cancer: A Western multicenter retrospective study
Authors: Francesca Blasa, Giuseppe Verlato, Hidde Overtoom, Martina Hermez Chole, Fabrizio Tedone, Federica Filippini, Markos Despotidis, Evgenia Mela, Tania Triantafyllou, Dimitrios Schizas, Dimitrios Theodorou, Magnus Nilsson, Suzanne Gisbertz, Maria Bencivenga Ioannis Rouvelas
Affiliation: General and Upper GI Surgery Division, Department of Surgery, University of Verona, Verona, Italy
Introduction: Gastric cancer is a biologically heterogeneous disease with variable patterns of lymph node (LN) metastasis influenced by tumor biology and anatomical location. Western data on LN dissemination in the context of multimodal treatment remain limited.
Objective: The aim of this study was to assess anatomical lymph node metastatic patterns of involvement following curative gastrectomy in relation to the three main histological subtypes (intestinal, diffuse, and mixed) and primary tumor location. The secondary outcomes included lymphatic spread in early gastric cancer, after neoadjuvant chemotherapy and according to microsatellite instability status.
Methodology: We conducted a retrospective multicenter study of 950 patients with resectable gastric adenocarcinoma who underwent curative intent gastrectomy with D1–D3 lymphadenectomy at five high-volume European centers. LN retrieval and metastatic involvement were analyzed according to tumor location, Lauren histotype, pathological stage, neoadjuvant chemotherapy, and microsatellite status. LN stations were evaluated individually and grouped into three anatomical tiers based on proximity to the stomach.
Results: Diffuse and mixed histotypes showed approximately double the incidence of LN metastasis compared with intestinal-type tumors, with significantly higher station-specific metastatic rates across multiple perigastric and selected second-tier nodes (P <0.05–0.001). Lymphatic spread followed reproducible, site-specific anatomical pathways according to tumor location (fundus, body, antrum), independent of histotype. In early gastric cancer (pT0–pT1), LN metastases were rare and almost exclusively confined to stations 3 and 4. Neoadjuvant chemotherapy reduced overall nodal burden without altering the anatomical distribution of metastatic stations. Despite deeper tumor invasion, MSI cancers exhibited significantly lower nodal involvement than MSS tumors, with higher rates of node-negative disease (49.3% vs. 41.3%) and fewer pN3 cases (15.9% vs. 27.7%; P =0.044).
Conclusions: Tumor location determines the anatomical pattern of LN spread, whereas histological and molecular features modulate metastatic risk and extent. Integrating Lauren histotype and MSI status with anatomically tailored lymphadenectomy may optimize oncologic adequacy while limiting unnecessary nodal dissection.
Keywords: Gastric cancer-Lauren classification-Lymph node metastases-Lymphadenectomy
9. GQ1001 and GQ1005: novel HER2-targeting ADCs with a stable ring-opening linker and site-specific LDC technology demonstrating improved safety, stability, and potent efficacy in preclinical gastric cancer models
Authors: Lei Huang 1, Gang Qin 2, Chengcheng Gong 3, Yan Shi 2, Lili Shi 2, Biyun Wang 3
Affiliation: 1 Changhai Hospital, Naval Medical University, Shanghai, China; 2 GeneQuantum Healthcare Co., Ltd., Suzhou, China; 3 Fudan University Shanghai Cancer Center, Shanghai, China
Introduction: Conventional HER2-targeting ADCs such as TDM1 and TDXd are limited by linker instability, random conjugationinduced heterogeneity, and offtarget toxicities. We developed GQ1001 (DM1 payload) and GQ1005 (DXd payload) using ligasedependent conjugation (LDC) and a prehydrolyzed ringopening linker to overcome these limitations.
Objective: To evaluate the preclinical efficacy, pharmacokinetics, stability, and safety of GQ1001 and GQ1005 in HER2positive gastric cancer models, including patientderived xenografts (PDX), ABCG2mediated resistant models, and TKI combinations.
Methodology: Both ADCs were generated via immobilized Sortase Abased LDC, yielding homogeneous DAR (GQ1001: DAR2, 99%; GQ1005: DAR4). The ringopening linker prevents retroMichael reaction. Efficacy was assessed in NCIN87 CDX, gastric PDX models (LD20017-201149, ST020103, ST020318), and ABCG2overexpressing NCIN87 tumors. Combinations with pyrotinib or tucatinib were tested. PK/toxicity studies were performed in rats and cynomolgus monkeys.
Results: GQ1001 showed >100fold lower free DM1 in monkey plasma than TDM1 (Cmax 1 vs 65 ng/mL); GQ1005 maintained stable DAR in human plasma (>96% at 96h) versus ~50% drop for TDXd, with a fivefold higher tumortoplasma payload exposure ratio (198.5 vs 39.7). In NCIN87 CDX, GQ1001 at 15 mg/kg achieved 110% TGI (p<0.001); GQ1005 at 10 mg/kg showed efficacy comparable to TDXd. In the LD20017-201149 PDX (HER2+++), GQ1001 plus pyrotinib induced complete response in 6/6 mice (supraadditive). In the trastuzumabresistant ST020103 PDX, the combination achieved 103% TGI (p=0.037). In ABCG2overexpressing TDXdresistant tumors, GQ1001 remained fully active, confirming DM1 is not an ABCG2 substrate. HNSTD in monkeys was 45 mg/kg for GQ1001 (vs 10 mg/kg for TDM1) and 60 mg/kg for GQ1005 (vs 30 mg/kg for TDXd), with no neurotoxicity, lung toxicity, or mortality observed.
Conclusions: GQ1001 and GQ1005, enabled by LDC and a stable ringopening linker, provide exceptional plasma stability, minimal offtarget payload release, and significantly improved safety margins compared to TDM1 and TDXd. Both demonstrate potent activity in HER2positive gastric cancer models, including trastuzumabresistant and ABCG2mediated TDXdresistant settings. GQ1001 combined with pyrotinib achieves complete remission in a gastric PDX model, supporting clinical development for refractory HER2positive gastric cancer.
Keywords: Gastric cancer; HER2; Antibody-drug conjugate; GQ1001; GQ1005; Ring-opening linker; Site-specific conjugation; Pyrotinib; ABCG2 resistance
10. Metabolomic Signatures of Plasma and Ascites in Gastric Cancer with Peritoneal Metastasis
Authors: Yeri Kim1, Seon-Kyu Kim2, Hyun Min Lee1, Jiyeon Kim1, Hye Sook Han3
Affiliation: 1Department of Cellular and Molecular Physiology, Yale School of Medicine, New Haven, CT, USA. 2Aging Convergence Research Center, Korea Research Institute of Bioscience and Biotechnology (KRIBB), Daejeon, South Korea 3Department of Internal Medicine, Chungbuk National University College of Medicine, Chungbuk National University Hospital, Cheongju, South Korea
Introduction: Peritoneal metastasis (PM) is a strong predictor of poor prognosis and therapeutic resistance in gastric cancer (GC). Despite its clinical significance, the metabolic alterations associated with PM remain poorly characterized due to the paucity of dedicated studies.
Objective: This study aimed to identify distinct metabolic signatures and dysregulated pathways in plasma and malignant ascites from GC patients with PM.
Methodology: Untargeted metabolomic profiling was conducted using liquid chromatography–mass spectrometry on plasma and ascitic fluid samples. Plasma samples were collected from three GC groups (n=24): early-stage GC, metastatic GC without PM, and metastatic GC with PM. Ascites samples were obtained from patients with cirrhosis-related benign ascites and GC-related malignant ascites (n=16). Multivariate statistical analyses—including principal component analysis, partial least squares discriminant analysis, and variable importance in projection scoring—were used to identify differentially expressed metabolites between groups.
Results: Plasma metabolomic profiling revealed distinct differences between early-stage and metastatic GC, with significant enrichment of nitrogen-related metabolites, particularly those involved in polyamine biosynthesis and the methionine cycle. Among metastatic cases, patients with PM showed more pronounced alterations in nitrogen-related pathways compared to those without PM. In malignant ascites, marked increases in carbohydrate metabolism—especially elevated levels of fructose and mannose—suggested enhanced gluconeogenesis and Warburg-like metabolic reprogramming. Although fewer metabolites were differentially expressed between benign and malignant ascites, nitrogen metabolism remained a prominently dysregulated pathway.
Conclusions: Nitrogen metabolism emerged as a shared metabolic hallmark of gastric cancer–associated peritoneal metastasis in both plasma and malignant ascites. Malignant ascites additionally displays increased carbohydrate metabolism. These findings highlight the unique metabolic reprogramming of the peritoneal tumor microenvironment and may offer potential targets for diagnostic and therapeutic strategies.
Keywords: Gastric cancerPeritoneal metastasisMetabolomics
11. Distinct Plasma Biomarker Signature of Marrow-Dominant Metastasis in Gastric Cancer–Associated Disseminated Carcinomatosis of the Bone Marrow
Authors: Yong-Pyo Lee1, Seung-Myoung Son2, Sun Kyung Lee1, Hye Sook Han1
Affiliation: 1Department of Internal Medicine, Chungbuk National University College of Medicine, Chungbuk National University Hospital, Cheongju, South Korea 2Department of Pathology, Chungbuk National University College of Medicine, Chungbuk National University Hospital, Cheongju, South Korea
Introduction: Disseminated carcinomatosis of the bone marrow (DCBM) is a rare but highly aggressive manifestation of gastric cancer characterized by diffuse marrow infiltration and severe hematologic complications. Although often considered an advanced form of bone metastasis, its underlying biology remains poorly understood.
Objective: We aimed to characterize the circulating biomarker profile of DCBM and to determine whether it represents a distinct metastatic phenotype.
Methodology: We performed multiplex plasma biomarker analysis in patients with advanced gastric cancer, comparing three groups: DCBM (n=15), conventional bone metastasis (n=14), and non–bone/non–bone marrow metastasis (n=25). Evaluated biomarkers included PTHrP, RANKL, CXCL12, TGF-β, osteopontin, and BMP-4. Overall survival (OS) was analyzed using the Kaplan–Meier method.
Results: Classical mediators of osteolytic bone destruction, including PTHrP (P=0.224) and RANKL (P=0.133), were not significantly elevated in DCBM compared with other groups. In contrast, DCBM exhibited a distinct circulating biomarker profile characterized by reduced CXCL12 levels (P=0.001) and increased levels of TGF-β (P=0.010), osteopontin (P=0.007), and BMP-4 (P=0.003). These alterations were not observed in conventional bone metastasis, which showed a profile comparable to non–bone/non–bone marrow metastasis.Median OS was significantly shorter in patients with DCBM than in non-DCBM patients (3.7 vs. 8.5 months, P<0.001). Among groups, median OS was 3.8 months (DCBM), 4.9 months (bone metastasis), and 10.7 months (non–bone/non–bone marrow metastasis) (P<0.001).
Conclusions: DCBM exhibits a circulating biomarker profile distinct from that of conventional bone metastasis and is associated with markedly poor survival. These findings support DCBM as a biologically distinct, marrow-dominant metastatic phenotype rather than a typical osteolytic process. Further studies are needed to elucidate its underlying mechanisms and therapeutic implications.
Keywords: Gastric cancerDisseminated carcinomatosis of the bone marrowPlasma biomarkers
12. The results of total gastrectomy with intestinal j-pouch interposition in surgical treatment of acute bleeding gastric cancer
Authors: Shepetko E.N.(1), Burburska S.V.(2), Bilyachenko M.V.(1), Shihadat T.M.(1)
Affiliation: Innovative Surgical Center „Adonis – Lab SP” (1), CEO LLC „Osteonica” (2). Kyiv, Ukraine.
Introduction: Surgical treatment of gastric cancer using radical operations is accompanied by a high rate of postoperative pathological syndromes (42%).
Objective: Improving the functional results of total gastrectomies (TG) in the long-term postoperative period remains a pressing problem today.
Methodology: Jejunogastroplasty (JGP) with the formation of an artificial intestinal reservoir (artificial stomach) was proposed to improve the results of TG. The results of 246 TG over 2 periods were analyzed: I (1983-1999) – 147 patients, II (2000-2023) – 99. Acute bleeding gastric cancer was present in 170 patients. Isolated TG was performed in 186 (75.6%) patients, combined — in 60 (24.4%). Formation of JGP after TG was performed in 41 patients (manually in 3, hardware in 38), with the inclusion of the duodenum in 39%.
Results: A significant reduction in postoperative mortality was achieved from 19% in the I period to 2% in the II period (9.5 times, p = 0.0001; χ2= 14.456). Mortality after isolated TG was 1.8 times less than after combined TG (10.2% and 18.3%, p = 0.1495; χ2= 2.078; p>0.05). Various options for forming the JGP were developed: 1) artificial intestinal reservoir from a triple loop of jejunum (triple anastomosis) on an off-line Roux-en-Y loop (14.6%); 2) Ω-loop JGP by suturing the afferent and efferent loops of the jejunum with a manual or hardware suture with the formation of a distal entero-enteroanastomosis by Brown (46.3%); 3) J-pouch interposition — an artificial intestinal reservoir (JGP) located between the esophagus and duodenum (39%).
Conclusions:
- The use of modern technologies (welding machine Patonmed, Harmonic, staplers) for TG and JGP reduces postoperative mortality by 9.5 times.
- The functional results of TG with the JGP were better after the modification of JGP with the inclusion of the duodenum in the digestive transit.
Keywords: total gastrectomy, gastric cancer, gastrointestinal bleeding, jejunogastroplasty
13. Metabolic Changes After Perioperative Chemotherapy and Gastrectomy
Authors: Tomasz Muszyński; Tomasz Jędrychowski; Kołodziejczyk Piotr; Piotr Richter.
Affiliation: I st Chair of General Surgery, Jagiellonian University Medical College and the Department of General, Oncological, Gastrointestinal Surgery and Transplantology, University Hospital in Cracow, Poland
Introduction: Gastric cancer accounts for approximately 800,000 deaths each year, ranking fifth in globalincidence and third in cancerrelated mortality . Malnutrition affects nearly 60% of patients. Gastrectomy performed for gastric cancer results in substantial nutritional alterations. These changes may persist long after surgery and can be further influenced by perioperative systemic treatment.
Objective: This study aimed to evaluate the longterm metabolic and nutritional effects of gastrectomy and perioperative chemotherapy.
Methodology: A prospective cohort of 37 patients with gastric cancer, eligible for perioperative chemotherapy and without metastatic disease, was enrolled. Assessments were performed preoperatively and at 6 and 12months after gastrectomy. Collected data included nutritional status parameters, demographic characteristics, and body composition assessment. Physical activity and quality of life was assessed.
Results: Significant postoperative changes were observed across multiple metabolic andnutritional parameters. Patients demonstrated reductions in body weight, muscle mass, andselected biochemical markers, alongside alterations in inflammatory indices. These findingsindicate a measurable metabolic burden associated with gastrectomy and perioperativechemotherapy. Variability in recovery patterns was noted between the 6 and 12monthevaluations, reflecting ongoing physiological adaptation.
Conclusions: Gastrectomy for gastric cancer, combined with perioperative treatment, leads tonotable and sustained metabolic and nutritional changes. The study highlights the importance of structured longterm monitoring to identify deficiencies, guide supplementation, and support recovery. Tailored nutritional strategies and rehabilitation programs may help mitigate postoperative complications and improve overall patient outcomes.
Keywords: gastrectomy, stomach cancer, chemotherapy, FLOT
14. Clinicopathological Profile of Gastric GISTs: A Retrospective Single-Center Cohort
Authors: Jéssica Rodrigues, João Pinho, Nuno Silva Gonçalves, Charlène Viana, Dina Luís, Joaquim Costa Pereira
Affiliation: Hospital de Braga
Introduction: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the digestive tract, with the stomach being the predominant location. Despite improvements in diagnosis and treatment, GISTs remain a heterogeneous group with variable biological behavior. Immunohistochemistry plays a key role in diagnosis, and factors such as tumor size, mitotic index, and mutational profile influence prognosis.
Objective: This study aims to describe the clinicopathological characteristics of surgically treated gastric GISTs in a tertiary center in Portugal.
Methodology: A retrospective study was conducted in a tertiary center in Portugal, including adult patients (≥18 years) who underwent surgical resection for histologically confirmed gastric GIST between 2017 and 2024. Demographic, clinical, surgical, and pathological data were extracted from medical records and analyzed. Tumor location, dimensions, mitotic index, immunohistochemical markers (CD117, DOG1, CD34, S100), and mutational status (KIT, PDGFRA) were included. Descriptive and comparative statistics were performed.
Results: A total of 49 patients were included, with a median age of 67 years and a slight female predominance (55%). The majority of tumors were located in the gastric body (61%), followed by the fundus and antrum. Most tumors had a low mitotic index and were classified as stage IA. CD117 and DOG1 were positive in 88% and 97% of cases, respectively. KIT mutations were present in 88% of tested cases, while PDGFRA mutations were rare (6%). Recurrence was infrequent and mainly associated with higher-risk tumors.
Conclusions: This study highlights the predominance of early-stage, immunopositive gastric GISTs in our cohort and reinforces the diagnostic value of DOG1 in CD117 – negative cases. Surgical resection remains effective, with favorable outcomes in most patients.
Keywords: Gastrointestinal stromal tumor, Gastric tumor, Gastric GIST, Clinicopathological features, Immunohistochemistry, KIT mutation
15. Oesophageal anastomotic leakage, a potentially deadly complication
Authors: BECHER Laura, UGGERI Fabio
Affiliation: General Surgery, IRCCS San Gerardo Dei Tintori, Monza, ITALY.
Introduction: A 45-year-old male with no significant past medical history presented to general practitioner in March 2023 with complaint of dysphagia to solids followed by referral to Upper GI surgery, IRCCS.
Objective: Clinical Findings and Diagnostic Assessment:An esophagogastroduodenoscopy (OGD) performed in May 2023 revealed a vegetative-ulcerative neoformation located approximately 40 cm from the incisors, involving up to the gastric fundus. Biopsies from the lesion confirmed the diagnosis of gastric adenocarcinoma. Further radiological investigations, including a CT scan of the thorax and abdomen, endoscopic ultrasound (EUS) and MRI of the abdomen, were conducted revealing uT3N+ Tumor.
Methodology: Therapeutic Interventions and Follow-up:In June 2023, the case was discussed at the Upper GI multidisciplinary team (MDT) meeting, and the decision was made to proceed with neoadjuvant chemotherapy, FLOTx4.A follow-up CT scan of the abdomen in September 2023 demonstrated a reduction in the size of the neoformation (from 22×42 mm to 15×35 mm) and a decrease in the size of the lymph nodes (from 50×35 mm to 36×26 mm).On October 4, 2023, the patient underwent an Ivor-Lewis esophagectomy.
Results: Postoperative Complications:On the fourth postoperative day (October 8, 2023), bile was noted in the peri-anastomotic drainage, and the patient exhibited elevated inflammatory markers. A contrast-enhanced CT scan of the abdomen revealed extravasation of oral contrast into the mediastinum adjacent to the esophagogastric anastomosis.Subsequent OGD confirmed an anastomotic leakage involving one-third of the anastomosis. An ENDO-SPONGE was positioned to bridge the anastomosis.The patient underwent a total of 12 endoscopic procedures, each performed every 3-4 days, until complete healing of the anastomotic leakage was achieved.
Conclusions: This case highlights the importance of a multidisciplinary approach in the management of gastric CA, the role of neoadjuvant chemotherapy in tumour size reduction, and the challenges of managing postoperative complications such as anastomotic leakage. The use of endoscopic therapies, such as the ENDO-SPONGE, proved effective in managing the challenging anastomotic leak effectively and non-invasively.
Keywords: ENDO-SPONGEpostoperative complicationsanastomotic leakIvor-Lewis esophagectomy
16. From Operating Room to Pathology Report: Delphi Consensus on Pathological Assessment of Peritoneal Cytology and Biopsies in Staging Laparoscopy for Gastric Cancer
Authors: Judith S.E. Quik, MD1; Micha J. de Neijs2,3; Heike I. Grabsch, MD PhD4,5; Niels A.D. Guchelaar, PhD3; Jan Erik Freund, MD PhD6; Lodewijk A.A. Brosens, MD PhD6; Lindsey Oudijk, MD PhD7,8; Marie-Louise F. van Velthuysen, MD PhD7;; Michail Doukas, MD PhD7; Petur Snaebjornsson, MD PhD9; Astrid Klooster, MD PhD10; Nienke Doddema7; Kay van den Burg9; Bas P.L. Wijnhoven, MD PhD2; Johanna W. van Sandick, MD PhD1; Sybren L. Meijer, MD PhD11, Liudmila L. Kodach, MD PhD7; on behalf of the collaborators*
Affiliation: 1Department of Surgical Oncology, the Netherlands Cancer Institute – Antoni van Leeuwenhoek, Amsterdam, the Netherlands.
Introduction: Staging laparoscopy with peritoneal cytology and biopsies is recommended in selected patients with gastric cancer (GC), but practical guidance for assessment of peritoneal lavage/ascites and peritoneal biopsies is lacking.
Objective: We aimed to develop consensus-based recommendations for handling, assessing and reporting of these specimens.
Methodology: A modified Delphi study was conducted among Dutch experts in GC (cyto)pathology. In round 1, sixty-two statements on clinical information, specimen requirements, initial assessment, ancillary testing, biomarker testing and reporting were rated on a 3-point scale (agree/neutral/disagree); consensus was predefined as ≥80% agreement. Non-consensus statements were discussed in an online meeting, informed by comments and literature review, revised, and re-rated in Round 2 on a dichotomous agree/disagree scale, with consensus defined as ≥70% agreement.
Results: Thirty-one experts from university, general, and independent pathology practices participated. Consensus was achieved for 39 of 62 statements (63%) in Round 1 and for 58 of 62 statements (94%) after Round 2. Consensus was achieved on required clinical information from surgeons, specimen submission and handling, cytological and histological assessment, use of ancillary immunocytochemistry/immunohistochemistry, structured reporting categories, and approaches to biomarker testing on peritoneal biopsies. The study also resulted in structured reporting templates for peritoneal cytology and biopsies.
Conclusions: This Delphi study achieved broad expert consensus on pathological assessment of peritoneal fluid and biopsies obtained during staging laparoscopy in GC patients. The resulting recommendations and structured reporting templates provide a practical framework to harmonise specimen handling, evaluation and reporting, thereby promoting greater standardisation and consistency in GC staging.
Keywords: Gastric cancer; Laparoscopy; Peritoneum; Cytodiagnosis; Delphi consensus
17. A randomized, multicenter clinical trial comparing the combination of perioperative FLOT and laparoscopic HIPEC in advanced gastric cancer (CHIMERA) – quality of life and safety analysis
Authors: Radoslaw Pach(1), Piotr Kolodziejczyk(1), Marek Sierzega(1), Wojciech Zegarski(2) , Wojciech Polkowski(3), Marek Bebenek(4), Krzysztof Szewczyk(4), Daromir Godula(1), Piotr Richter(1)
Affiliation: (1) First Department of General Surgery, Jagiellonian University, Medical College, Krakow, Poland (2) Department of Surgical Oncology, Nicolaus Copernicus University in Torun, Collegium Medicum in Bydgoszcz, Poland (3)Department of Surgical Oncology, Medical University of Lublin, Lublin, Poland (4) Department of Surgery, Lower Silesian Oncological Centre, Wroclaw, Poland
Introduction: Peritoneal metastasis is one of the most important prognostic factors in gastric cancer. Despite perioperative chemotherapy, peritoneal recurrence develops in 10–46% of patients following gastrectomy. The addition of hyperthermic intraperitoneal chemotherapy (HIPEC) to the current standard treatment regimen may provide an additional therapeutic benefit.
Objective: This study aimed to evaluate the efficacy and safety of perioperative FLOT chemotherapy combined with preoperative laparoscopic hyperthermic intraperitoneal chemotherapy (LHIPEC) in patients with advanced gastric cancer.
Methodology: This phase III multicenter randomized controlled trial enrolled patients with advanced gastric cancer who underwent exploratory laparoscopy after completing four cycles of preoperative FLOT chemotherapy. During laparoscopy, patients were randomly assigned to one of two treatment groups. The experimental arm received preoperative LHIPEC with irinotecan followed by gastrectomy, whereas the control arm received standard treatment. The study endpoints included peritoneal recurrence rate, overall recurrence rate, overall survival, disease-free survival, postoperative complication rate, and quality of life assessed using the EORTC QLQ-C30 and STO22 questionnaires. Trial registration: ClinicalTrials.gov identifier NCT04597294, prospectively registered on October 15, 2020; EudraCT number 2020-001419-25.
Results: Between 2022 and 2024, a total of 47 patients were enrolled. Thirty two patients were randomized, and 17 received LHIPEC. Preoperative LHIPEC did not increase the rate of postoperative complications following gastrectomy or during adjuvant chemotherapy. No anastomotic leaks were observed among patients who underwent surgery after prophylactic LHIPEC. Furthermore, the experimental arm showed no increase in septic complications.The mean baseline global quality-of-life score (QLQ-C30) was 67.7%, compared with 65.4% at the end of the study (p = 0.313). At baseline, patients in the experimental arm reported more severe symptoms on the STO22 questionnaire. By the end of the study, improvements were observed in several symptom domains, including abdominal pain, dysphagia, reflux, vomiting, dry mouth, and eating restrictions.This study represents the first prospective multicenter randomized trial to investigate neoadjuvant HIPEC with irinotecan as an adjunct to perioperative FLOT chemotherapy in patients with advanced gastric cancer. Following the enrollment of 47 patients and the randomization of 32 patients according to the study protocol, the trial was terminated prematurely because of low patient accrual.
Conclusions: The addition of preoperative LHIPEC to perioperative FLOT was safe and well tolerated, without increasing postoperative complications or negatively affecting quality of life. Although these findings support the feasibility of this approach, the premature termination of the trial precluded definitive conclusions regarding its oncological efficacy.
Keywords: advanced gastric cancer; prophylactic laparoscopic hyperthermic intraperitoneal chemotherapy; complications; quality of life
18. Ten-year of french multicentric experience in the management of metastatic gastric cancer : 20965 patients
Authors: Dr Constance LaroyeXavier LenneDr Julie VeziantPr Guillaume PiessenPr Clarisse Eveno
Affiliation: Surgical oncologic department, Lille University Hospital, France
Introduction: Gastric cancer (GC) is an aggressive tumor, with limited survival, and predominantly non-surgical treatment, especially when associated with metastasis. Only few expert centers treat peritoneal metastasis of gastric cancer (PMGC) with cytoreductive surgery (CRS) and HIPEC in selected patients.
Objective: The aim of the study is to review current practices in the management of synchronous metastatic gastric cancer in France over 10-years
Methodology: All patients in France between 2014 and 2023 were identified through a national medical database. Patients and perioperative outcomes were analyzed and divided into three groups according to their treatment: best supportive care (BSC), chemotherapy alone (Chemo), or surgery (Surg group).
Results: Of the 20965 patients,16634 (79.3%) were treated with a palliative intent, [with best supportive care (n=5630, 26.8%) or chemotherapy (n=11004, 52.5%)], or with a curative intent, involving chemotherapy and surgery (n=4331,20.7%). Patients in the BSC group were older and had more comorbidities, with a median overall survival (OS) of 1.6months, compared to 11.7 and 28.1months in the Chemo and Surg groups, respectively. For the Surg group, the peritoneal metastasis (PM) group had the worst prognosis, with a mean OS of 21months, compared to 31months for lymph node (LN) metastasis, 25months for liver (HM) and lung (LM) metastasis. Patients underwent total gastrectomy in 59.8% of cases, with major morbidity (MM) and post-operative mortality (POM) at 90days of 31.6 and 9.8%, respectively. Focusing on PMGC (n=885), of the 272 patients (30.7%) treated with CRS+HIPEC, 85% in university centers. A total gastrectomy was performed in 88.6% of cases, by laparotomy. The MM rate was 37% for CRS-only and 60% for CRS+HIPEC, with 20% and 37% abdominal complications, respectively. POM at 90days was double in the CRS-only group at 13%, compared to 6% in the CRS+HIPEC group. Despite a higher MM rate, the failure-to-rescue rate was lower in the CRS+HIPEC group than in the CRS-only group (9.1% vs. 6.6%, p<0.01).OS was better in the CRS+HIPEC group at 19 months compared to 14 months without HIPEC
Conclusions: Our study is one of the largest in gastric cancer with synchronous metastasis, based on 20965 patients.It focuses on patient characteristics, treatment strategies depending on metastasis, and overall survival.In the peritoneal field, complete CRS combined with HIPEC has been shown to lead to better postoperative outcomes and improved long-term survival.
Keywords: astric cancerCytoreductive surgeryHIPECChemotherapyPrognosisBest supportive careMetastasesSurgeryPeritoneal metastases
19. Quality of life and decision regret after laparoscopic total gastrectomy in CDH1-mutation carriers
Authors: Erik Makitalo, Gisele Aaltonen, Johanna Louhimo, Anne Juuti, Arto Kokkola
Affiliation: University of Helsinki
Introduction: Pathogenic or likely pathogenic CDH1-germline mutation carriers are at high risk of developing diffuse gastric cancer (DGC). Current guidelines recommend total gastrectomy (TG) for CDH1-mutation carriers at the age of 20-30 years to reduce the risk of DGC. TG is frequently associated with significant postoperative morbidity and severe complications. Major lifestyle changes and postoperative morbidity may impact health related quality of life (HRQOL) of preoperatively healthy and young CDH1-mutation carriers. The decision to pursue TG may be associated with anxiety and regret.
Objective: To evaluate health related quality of life and decision regret in CDH1-germline mutation carriers who were set to undergo laparoscopic total gastrectomy, and to identify possible factors impacting HRQOL and decision regret.
Methodology: Patients included in our study were carriers of a P/LP CDH1-germline mutation and set to undergo laparoscopic TG between 2017 and 2025. Health related quality of life and decision regret data was collected using EORTC -C30, -STO22 and DRS questionnaires. Patient characteristics and surgical data was obtained from electronic patient records.
Results: A total of 36 patients underwent laparoscopic TG at a mean age of 41.8 years. Severe postoperative complications occurred in 7 (19.4%) patients. Signet ring cell carcinoma (SRCC) was found in 21 patients (58.3%). 28 patients elected to participate in the HRQOL survey study. HRQOL was comparable to that of the general population and DR was low. Patients experienced long-term fatigue, nausea and vomiting, appetite loss, and diarrhea. Preoperative normal BMI and female sex were associated with more frequent postoperative symptoms. Severe complications or SRCC absent on pathology did not impact DR.
Conclusions: HRQOL remains high although symptoms do persist after a laparoscopic TG in CDH1-mutation carriers. A laparoscopic approach may benefit in less long-term pain. Women and patients with preoperatively normal BMI have lower HRQOL scores and more frequent postoperative symptoms. DR remains low after a laparoscopic TG.
Keywords: CDH1-mutation, Total gastrectomy, Gastric cancer, Prophylactic surgery
20. Organ sparing surgery for early gastric cancer
Authors: Benzoni Ilaria ASST CREMONA ~ Cremona ~ ItalyLaurenza Carmen ASST CREMONA ~ Cremona ~ ItalyMorelli Marta Department of Clinical and Experimental Sciences, University of Brescia, and ASST Cremona, Italy ~ Cremona ~ ItalyOttaviani Luca ASST CREMONA ~ Cremona ~ ItalyFrittoli Barbara Department of Radiology, ASST Spedali Civili, Brescia ~ Brescia ~ ItalyGrassia Roberto ASST CREMONA ~ Cremona ~ ItalyBaiocchi Gian Luca Department of Clinical and Experimental Sciences, University of Brescia, and ASST Cremona, Italy ~ Cremona ~ Italy
Affiliation: Department of Surgery, ASST Cremona
Introduction: The aim of our monocentric observational study is to evaluate the feasibility and preliminary results of laparoscopic sentinel node navigation surgery with indocyanin green (ICG), applying SENORITA protocol in a Western center, in patients with early gastric cancer. Sentinel node navigation surgery reduces the extent of gastric and lymph node dissection and improves quality of life. The SENORITA (a Korean well established protocol), aims to evaluate the feasibility of organ sparing gastric surgery with ICG lymph node navigation compared to standard laparoscopic gastrectomy for early gastric cancer.
Objective: We conducted an uncontrolled single-centre, prospective analysis, with the aim of evaluating surgical radicality and post- partial gastrectomy quality of: life.
Methodology: We analyzed 24 patients that underwent surgery at ASST Cremona with adenocarcinoma clinical staging cT1N0M0 from February 2022 to december 2025. All patients underwent preoperative staging with EGDS, CT and EUS. The first endpoint was the feasibility of the intervention related to the postoperative quality of life. Secondary outcomes consisted of the radicality of the intervention on the T and N parameters, duration of the surgery, post- operative complications, hospitalization times, hospital readmission, the need for other procedures and oncological follow-up.
Results: 24 patients were included in the analysis. In 11 cases total gastrectomy would have been required for tumor location. Mean operative time was 149 AND minutes, 50% of patients underwent combined ESD and laparoscopic nodal harvesting . Mean follow up was 19 ,9 months ( range 2 – 4 5 ) . Organ preservation rate was 83,4%. Four patients developed surgical complications due to edema of the suture-line and consequent pyloric occlusion. Incidence of complication CD more than 3 was.8,3%.
Conclusions: In selected cases of early gastric cancer, gastric wedge resection associated to sentinel-nodes basin removal, is a feasible and safe option that and it could achieve a safe oncological result; patient selection is of paramount importance.
Keywords: Organ sparing, mininvasive surgery, ICG, nodal navigation
21. The gastroscreening project : state of the art and preliminary results
Authors: Benzoni Ilaria ASST Cremona ~ Cremona ~ ItalyOttaviani Luca ASST Cremona ~ Cremona ~ ItalyQuarti Luca ASST Cremona ~ Cremona ~ ItalyCelotti Andrea ASST Cremona ~ Cremona ~ ItalyTurco Nicolò Department of Clinical and Experimental Sciences, University of Brescia, and ASST Cremona, Italy ~ Brescia ~ ItalyNoventa Chiara Department of Clinical and Experimental Sciences, University of Brescia, and ASST Cremona, Italy ~ Brescia ~ ItalyElvo Biagio ASST Cremona ~ Cremona ~ ItalyBencivenga Maria Department of Surgery, General and Upper G.I. Surgery Division, University of Verona, Italy ~ Verona ~ ItalyGrassia Roberto ASST Cremona ~ Cremona ~ ItalyGiacopuzzi Simone Department of Surgery, General and Upper G.I. Surgery Division, University of Verona, Italy ~ Verona ~ ItalyVerlato Giuseppe Department of Diagnostic and Public Health, University of Verona, Italy ~ Verona ~ ItalyBaiocchi Gian Luca Department of Clinical and Experimental Sciences, University of Brescia, and ASST Cremona, Italy ~ Brescia ~ Italy
Affiliation: Department od Surgery, ASST Cremona ~ Cremona ~ Italy
Introduction: Despite gastric cancer representing one of the leading causes of cancer death in Italy , there is no large-scale approved screening test.
Objective: We created a questionnaire to detect gastric cancer risk factors and „alarm symptoms” in the target population and the identification of patients most in need of EGDS. After an umbrella review 75 determinants were selected for inclusion in a questionnaire (Gastroform 2.0) designed for population-level administration. The selected determinants and their associated relative risks formed the basis of a predictive algorithm designed to estimate individual gastric cancer risk and identify most at risk individuals.
Methodology: The feasibility of the process was easily tested with a pilot project at our center; we obtained the approval to extend the study to other ten Endoscopy Units around Italy.
Results: Starting from January 2026 the Gastroform 2.0 was administered to patient out of 425 EGDS performed among 7 endoscopy referral centers. 46,8 % of the patients were asymptomatic, 3,13% reported alarm symptoms(such as pathologic fatigue, melena, emathemesis, pathologic weight loss),50% of the sample reported aspecific symptoms. Mean age was 63, 14% of the sample reported to be an active smoker, 38% reported regular sport, and 18,7% heavy alcohol consumption (more than one unit per day). From the histological point of view, Barret’s incidence was 1,5%, erosive esophagitis detection rate was 14,15, Incidence of atrophic gastritis was 14,06%.
Conclusions: It is possible to administer a questionnaire providing useful informations to identify a population most likely to have significant endoscopic findings in early diagnosis during a screening EGDS.
Keywords: early gastric cancer, screening, predictive algorithm
22. Perioperative red blood cell transfusion exceeds the risk of anaemia in patients undergoing gastrectomy for cancer.
Authors: Daromir Godula, Marta Walczak, Łukasz Bobrzyński, Piotr Richter, Marek Sierzega
Affiliation: First Department of Surgery, Jagiellonian University Medical College, Cracow, Poland
Introduction: Anaemia is highly prevalent in patients with gastric cancer and many of them require perioperative red blood cells transfusion. However, little is known about the long-term implications of anaemia and whether they could be corrected by RBC transfusions.
Objective: Evaluate the effects of anaemia and perioperative blood transfusion for postoperative complications and long-term survival.
Methodology: A prospectively maintained electronic database of 1089 patients undergoing elective surgical resections with a curative intent between 1996 and 2020 was reviewed. Anaemia was defined and graded using haemoglobin cutoffs developed by the National Cancer Institute guidelines. The effects of anaemia grades as well as timing and volume of RBC transfusions were evaluated by logistic regression models and Cox proportional hazards models.
Results: Preoperative anaemia was diagnosed in 543 (49.9%) patients and 333 (32%) required RBC transfusions. Patients with anaemia more often required multiorgan resections (32% vs 25%, P= 0.005) and were less likely to achieve complete R0 resections (80% vs 85%, P= 0.034). The median Comprehensive Complication Index (CCI) was higher in patients with anaemia (21 vs 0, P<0.001), but there were no differences in rates of serious complications (Clavien–Dindo grade 3), mortality, or reoperations. RBC transfusion was associated with an overall morbidity (53% vs 31%, P<0.001) and severe complications (27% vs 16%, P<0.001) but not mortality. Normal haemoglobin level was associated with a significantly longer overall median survival (44.3 vs 22.4 months, P<0.001). Patients with perioperative transfusions had significantly shorter median survival (15.3 vs 44.8 months, P<0.001). Moreover, any transfusion impaired survival regardless of the initial haemoglobin levels. A Cox proportional hazards model failed to demonstrate preoperative anaemia as an important risk factor for patients’ survival (HR 1.07, 95% CI 0.91–1.24, P=0.424. Nevertheless, RBC transfusion was an independent negative prognostic factor (HR 1.19, 95% CI 1.00–1.42, P=0.045).
Conclusions: Detrimental long-term effects of RBC transfusions suggest a more conservative policy for preoperative anaemia in patients with gastric cancer.
Keywords: gastric cancer, anaemia, red blood cell transfusion, complications, prognosis
23. Not every abdominal complication is the same: perioperative and long-term sequela of postgastrectomy complications.
Authors: Marek Sierzega, Daromir Godula, Marta Walczak, Łukasz Bobrzyński, Piotr Richter
Affiliation: First Department of Surgery, Jagiellonian University Medical College, Cracow, Poland
Introduction: Previous studies related to gastrointestinal malignancies suggest that the presence of intra-abdominal complications may adversely affect not only postoperative mortality but also long-term survival. However, little is known about the relative importance of individual complications following stomach resections for gastric cancer.
Objective: Evaluate the effects of anastomotic leakage, duodenal leakage, pancreatic fistula, and abdominal abscess on postoperative outcomes and long-term survival.
Methodology: A prospectively maintained electronic database of 1792 patients treated between 1996 and 2020 in an academic surgical centre was reviewed. Candidate predictors of postoperative morbidity were evaluated using logistic regression models and Cox proportional hazards models were used to identify prognostic factors.
Results: The incidence of anastomotic leakage, duodenal leakage, pancreatic fistula, and abdominal abscess was 77. (4.3%), 81 (4.5%), 55 (3.1%), and 79 (4.4%). All these complications were significantly associated with higher Comprehensive Complication Index scores, reoperations, prolonged hospital stay, and mortality. However, the Cox proportional hazards model identified anastomotic leakage and duodenal leakage as the only complications associated with impaired long-term survival with HR of 2.37 (95%CI 1.84 – 3.05, P<0.001) and 1.34 (95% CI 1.02 – 1.77, P=0.038), respectively.
Conclusions: Abdominal complications pose varying risk levels for short- and long-term outcomes. The occurrence of anastomotic leakage and duodenal fistula were the main independent prognostic factors for long-term survival.
Keywords: gastric cancer, anastomotic leak, duodenal fistula, pancreatic fistula, abdominal abscess, complications, mortality, prognosis
24. Routine nasogastric decompression versus no decompression after gastrectomy for gastric cancer: a systematic review
Authors: Michele Barbiero, Francesca Sbuelz, Rossella Reddavid
Affiliation: Department of Surgical Sciences, University of Turin
Introduction: For decades, routine prophylactic nasogastric or nasojejunal decompression was considered standard practice after gastrectomy. Despite current ERAS recommendations discouraging its routine use, variations in clinical practice persist, and the overall evidence has not been recently synthesized.
Objective: Therefore, this systematic review aimed to evaluate the clinical outcomes associated with prophylactic decompression versus no decompression following gastrectomy for gastric cancer.
Methodology: A systematic review was performed according to PRISMA guidelines, querying Ovid MEDLINE, Embase, and Cochrane CENTRAL databases without time or language restrictions. Comparative randomized and non-randomized studies evaluating prophylactic nasogastric (NGT) or nasojejunal tube (NJT) decompression versus no decompression in adult patients undergoing elective subtotal or total gastrectomy for gastric adenocarcinoma were included. The primary endpoint was anastomotic leakage. Secondary endpoints included mortality, morbidity, pulmonary complications, functional recovery (time to flatus and oral diet), length of hospital stay (LOS), and tube reinsertion rates.
Results: Fourteen studies (9 RCTs, 4 retrospective, 1 prospective) encompassing 2.823 patients were included. The incidence of anastomotic leakage showed no significant difference between the decompression and no-decompression groups. Mortality and time to flatus were also comparable. However, the NGT/NJT group exhibited a higher incidence of postoperative pulmonary complications. Conversely, omitting decompression was consistently associated with an earlier resumption of oral diet (0.2–1.5 days) and a shorter hospital stay in most studies. Reinsertion rates in the no-decompression group (0-13%) were comparable to early removal/reinsertion rates in the decompressed group.
Conclusions: Routine omission of prophylactic NGT/NJT after gastrectomy for gastric adenocarcinoma appears safe and clinically advantageous. It is associated with improved postoperative recovery without increasing the risk of anastomotic leakage.
Keywords: Nasogastric decompression, Gastrectomy, Gastric Cancer, Nasogastric Tube, Enhanced Recovery After Surgery, Systematic Review
25. Role of low – intensity laser radiation in reducing complications of bougienage and expanding the possibilities of forced dilation in the early post-burn period
Authors: Nizamkhodjaev Z.M., Ligay R.E., Khadjibaev J.A., Omonov R.R., Tsoy A.O., Madrakhimov Sh.N., Avalbaev J.M., Khudoyshukurov S.A.
Affiliation: Republican Specialized Scientific and Practical Medical Center of Surgery named after academician V. Vakhidov
Introduction: The main method of treating post-burn cicatricial esophageal strictures (PCES) remains bougienage; however, it is accompanied by intraoperative and postoperative complications that limit the use of the more effective forced dilation regimen, especially in the early post-burn period.
Objective: Aim of the study: to evaluate the effect of intraluminal low-intensity laser radiation (LILR) on the incidence of esophageal bougienage complications and to determine whether reducing the number of complications allows forced bougienage to be used in patients with PCES in the early post-burn period.
Methodology: The study included 123 patients with PCES within 6 months of the burn. The comparison group (CG) comprised 56 patients who underwent isolated bougienage; the main group (MG) comprised 67 patients in whom bougienage was combined with intraluminal laser therapy. Clinical, radiological, and endoscopic monitoring methods were used.
Results: The overall complication rate was 21.4% in the CG versus 10.5% in the MG; the difference did not reach statistical significance (χ²=2.816; p=0.093) due to the relatively small number of events, although the clinical reduction exceeded twofold. Bleeding occurred in 6 (10.7%) CG patients and 4 (6.0%) MG patients; non-penetrating injuries occurred in 5 (8.9%) and 3 (4.5%), respectively. Iatrogenic penetrating injury of the esophageal wall was observed exclusively in the CG, in 1 (1.8%) patient; no such complication was recorded in the MG. The reduction in complication rate with LILR allowed a significant expansion of forced bougienage use: its proportion in the MG was 79.1% versus 12.5% in the CG (χ²=54.161; p<0.001). In the CG, forced bougienage was used only for short strictures, whereas in the MG it was used for strictures of any length, including subtotal (77.3%) and total (53.8%).
Conclusions: intraluminal LILR clinically reduces the incidence of bougienage complications in the early post-burn period and significantly (p<0.001) expands the possibilities for the safe use of forced bougienage in PCES of any length.
Keywords: post-burn cicatricial esophageal strictures, bougienage
26. Anticoagulation and Survival in Gastric Cancer Patients: a nationwide Finnish register study
Authors: Auvinen A, Aaltonen P, Mustonen H, Caj Haglund, Puolakkainen P*, Seppänen H**Share equal last authorship
Affiliation: Department of Surgery, Translational Cancer Medicine Research Program, iCAN Digital Precision Cancer Medicine Flagship, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
Introduction: The association between cancer and venous thromboembolism (VTE) is well established. VTE around gastric cancer (GC) diagnosis is associated with poorer prognosis. Current international guidelines suggest extended thromboprophylaxis up to 4 weeks after abdominal and pelvic cancer surgery, while suggest no routine thromboprophylaxis for patients going through medical oncological treatment unless they are at 'high risk’ for thrombosis. Currently, there are no guidelines regarding GC specifically
Objective: This nationwide study aims to evaluate whether anticoagulant (AC) use in an outpatient setting is associated with improved survival outcomes among GC patients in Finland.
Methodology: Patients with GC diagnosed in 2012–2016 were identified from the Finnish Cancer Registry. Information on AC prescription purchases, healthcare utilization, and mortality through the end of 2023 was collected. Cox proportional hazards model was used to estimate hazard ratios (HRs) for overall survival for pre- and post-diagnostic AC use. Patients were stratified by resection status a priori.
Results: A cohort of 2485 of histologically confirmed GC patients was included in the study. A protective effect of post-diagnostic AC use was found for non-resected patients (hazard ratio (HR) 0.82, 95% confidence interval (CI) 0.73–0.92, p=0.001), but not for resected patients (HR 1.21, 95% CI 1.01–1.45, p=0.034). Additionally, use of outpatient perioperative AC did not have a significant effect on mortality (HR 0.88, 95% CI 0.74–1.06, p=0.2). No significant effect was found for pre-diagnostic use in either group
Conclusions: We found no evidence that AC use would improve overall survival for patients who had GC surgery. However, it was associated with lower overall mortality for palliative patients. Further research should focus on which non-resectable patients specifically could benefit from thromboprophylaxis
Keywords: gastric cancer, epidemiology, anticoagulation, venous thromboembolism
27. Organ sparing surgery for EGJ cancer
Authors: Benzoni Ilaria ASST CREMONA ~ Cremona ~ ItalyOttaviani Luca ASST CREMONA ~ Cremona ~ ItalyQuarti Luca ASST CREMONA ~ Cremona ~ ItalyCelotti Andrea ASST CREMONA ~ Cremona ~ ItalyBonafede Martina Department of Clinical and Experimental Sciences, University of Brescia, and ASST Cremona, Italy ~ Cremona ~ ItalyRaschiani Andrea Department of Clinical and Experimental Sciences, University of Brescia, and ASST Cremona, Italy ~ Cremona ~ ItalyFrittoli Barbara Department of Radiology, ASST Spedali Civili, Brescia ~ Brescia ~ ItalyGrassia Roberto ASST CREMONA ~ Cremona ~ ItalyBaiocchi Gian Luca Department of Clinical and Experimental Sciences, University of Brescia, and ASST Cremona, Italy ~ Cremona ~ Italy
Affiliation: ASST CREMONA ~ Cremona ~ Italy
Introduction: With the increase of median age and proximal tumours, it is worth to offer to patients with early gastric cancer treatments looking to post-operative mortality risk and quality of life. Several endoscopic and laparoscopic approaches, such as endoscopic submucosal dissection and function-preserving gastrectomy have been accepted as standard treatments, especially in the Eastern countries.
Objective: To explore the feasibility of stomach preservation techniques associated to fluorescence-guided nodal basin harvesting in western setting, for early gastric cancer.
Methodology: We present the case of a 73 years old male that underwent an EGDS for sof+; a 25 millimeters non polipoid subcardial lesion was found. The patient was staged T1N0M0 with EUS and CT scan and referred to our center. After a multidisciplinar counseling, and considering the cardiological comorbidities (ASA3) the patient chose to undergo organ sparing surgery and ICG guided lymphonodal dissection with radical intent and agreed to complection surgery in case of the findion of a more advanced lesion.
Results: Endoscopic phase: Endoscopy confirmed the presence of a non polypoid lesion in the sub cardial region. Due to the proximity to the gastroesophageal junction (EGJ), endoscopic resection was considered technically unfavorable. Surgical resection was therefore planned. Preoperative indocyanine green (ICG) marking (0.25 mL) was performed.Surgical phase: Laparoscopic access was achieved using a Veress needle and an optical trocar. No evidence of peritoneal or hepatic metastatic disease was identified. Additional operating trocars were inserted under direct vision. The ICG marking was clearly identified at the EGJ. Three 10 mm intragastric trocars were placed, and intragastric surgery was performed. The lesion was excised down to the muscular layer; Nasogastric tube was positioned under direct vision, and the gastric accesses were closed with barbed sutures. Lymphatic drainage pathways were successfully identified using ICG fluorescence: lymph node sampling was performed in stations 1, 2, 3, 7, and 9. A drain was positioned. Operative time was 134 minutes, blood loss was not relevant. Postoperative course was uneventful, patient was started on a liquid diet from postoperative day (POD)1; drain was removed in POD 4 and the patient was discharged in POD5.Histological report confirmed a T1b lesion, 8 lymphnodes were harvested, none was metastatic. The patient did not experience weight loss or dysphagia, follow up is now 48 months.
Conclusions: The nodal basin harvesting guided by fluorescence, associated with sparing stomach resection techniques, is feasible from a technical point of view; This strategy should be further investigated, with special interest in older patients with early gastric cancer of the upper stomach, with the aim to spare total gastrectomy and its functional sequelae.
Keywords: organ sparing surgery, intragastric surgery, gastric cancer, EGJ cancer
28. Robotic Proximal Gastrectomy with Esophagojejunal Semimechanical Anastomosis and Double Tract Reconstruction for Early Gastric Cancer in Juvenile Polyposis Syndrome
Authors: Davide Citterio, Carlo Sposito, Camillo Franzetti and Vincenzo Mazzaferro
Affiliation: Fondazione IRCCS Istituto Nazionale Tumori Milano
Introduction: Proximal gastrectomy (PG) is a function-preserving surgical option for selected proximal early gastric cancers, recommended by Japanese gastric cancer treatment guidelines but still rarely adopted in Western surgical practice. Double tract reconstruction (DTR) is recognized as an effective reconstructive option after PG, providing excellent anti-reflux efficacy and favorable postoperative nutritional outcomes. Robotic surgery may further facilitate complex reconstructive steps, particularly esophagojejunal anastomosis.
Objective: To demonstrate the feasibility and technical details of robotic PG with semimechanical esophagojejunal anastomosis and DTR for early gastric cancer arising in Juvenile Polyposis Syndrome.
Methodology: A 30-year-old female affected by Juvenile Polyposis Syndrome associated with an SMAD4 mutation presented with a large 6 × 3 cm cardial polyp not amenable to endoscopic resection. Due to the high risk of maligncy and the near-circumferential involvement of the cardia, robotic proximal gastrectomy with lymphadenectomy and DTR was planned.The robotic platform was articularly exploited to perform the esophagojejunal anastomosis. A semimechanical technique was adopted, consisting of a side-to-side linear stapled posterior wall anastomosis followed by hand-sewn closure of the anterior wall. Jejunogastric and jejunojejunal anastomoses were completed using linear staplers.
Results: The postoperative course was uneventful. Oral intake was initiated on postoperative day (POD) 3, and the patient was discharged on POD 6 without complications. Final histopathology demonstrated a pT1aN0 gastric adenocarcinoma with 25 lymph nodes retrieved. The semimechanical robotic esophagojejunal anastomosis proved technically feasible and reproducible.
Conclusions: Robotic proximal gastrectomy with double tract reconstruction represents a safe and effective organ-preserving alternative to total gastrectomy for selected early neoplasms of the upper third of the stomach. The robotic approach may enhance the precision of reconstructive steps, particularly semimechanical esophagojejunal anastomosis, while maintaining favorable short-term surgical and oncological outcomes.
Keywords: Proximal gastrectomyDouble-tract reconstructionEarly gastric cancer
29. Sex and age-related prognosis and years of life lost for patients with early gastric cancer.
Authors: Elfriede Bollschweiler (1), Arnulf H. Hölscher (2), Brigitte Schumacher (3), Oliver Pech (4) und Patrick S. Plum (5).
Affiliation: 1. Medical Faculty, University of Cologne| 2. Center for Esophageal Diseases, Elisabeth-Krankenhaus Essen | 3. Klinik für Gastroenterologie, Universitätsmedizin Essen| 4. Klinik für Gastroenterologie und Interventionelle Endoskopie, Krankenhaus Barmherzige Brüder Regensburg | 5. Universitätsklinik für Allgemein-, Visceral- und Transplantationschirurgie, Tübingen, Germany
Introduction: Patients with pT1 adenocarcinoma of the stomach (EGC) have good prognosis following successful endoscopic or surgical treatment, with a 5-year survival probability (5y-SR) of around 68 per cent. However, data from the German Cancer Registry (DKR) also show that patients who have died have lost years of life expectancy (YLL) compared with the general population. The question is whether there are age-related differences between the sexes in this regard.
Objective: We analysed data from the German Cancer Registry to answer this question
Methodology: Between 2010 and 2020, 5,566 patients with EGC were reported to the DKR. Follow-up continued until 2022, with a median duration of 6.5 years. Incidence rates, 5y-SR and YLL, broken down by gender and age group – <50 years, 50–59 years, 60–69 years and 70 years or older at the time of initial diagnosis – were analysed.
Results: The sex ratio was 3:2, with 3,397 males and 2,169 females, and did not differ from that of the overall gastric cancer population in Germany. Analysis by age group revealed a significant trend in the proportion of female, ranging from 36.7% to 40.6% (p<0.01), with increasing age. During the follow-up period, 41,7% of patients died, median 2,5 years after diagnosis. Women were affected significantly less frequently (39%) compared with men (43%) (p=0.0006). The mortality rate rose from 10%, 22% and 30% to 53% for males, and from 9%, 11% and 23% to 49% for females in the different age groups. The prognosis for women was significantly better, with a 5y-SR of 70% compared with 65% for men (p=0.0002). Taking age groups into account, the 5y-SR were as follows: for those aged <50 years: m=91%, f=94% (n.s.); age 50–59 years: m=81%, f=91% (p=0.0009), age 60–69 years: m=77%, f=86% (p=0.0001) and age 70 years or older: m=57%, f=62% (p=0.0012).Patients who died during the follow-up period lost a median of 6.8 years of life. For women in the under-70 years age groups, the number of YLL was significantly higher than for men of the same age.
Conclusions: Women are less likely to develop gastric cancer. This also applies to the diagnosis of early-stage gastric cancer. The prognosis for women with pT1 gastric cancer is significantly better than that for men of the same age. Death within the first 5–10 years following diagnosis results in a relevant loss of life years, and this affects younger women in particular.
Keywords: early gastric cancer, prognosis, sex-related prognosis, age-related prognosis, years of life lost
30. The oncological efficacy of D2+CME for locally advanced gastric cancer: 5-year outcomes of DCGC01 trial
Authors: Daxing Xie, Jie Shen, Jianping Gong
Affiliation: Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology
Introduction: More and more evidences revealed that the omentum and bursa sac is not mesogastrium. Traditional opinion described that the bursa omentalis is a part of the dorsal mesogastrium, therefore the radical gastrectomy include two parts, i.e. total resection of the bursa omentalis and extended lymphadenectomy outside of the bursa sac. However, oncologic benefit had not been proved in this model, but with higher surgery hazard. With endoscopic surgery development, we found that real proximal segment of dorsal mesogastrium (PSDM) is hided beneath of the omentum and outside of the bursa sac, as a “table model” shape. So that, we propose that complete resection of PSDM in D2 field (D2+CME）is a rational procedure, which comparing the traditional D2. A randomized control trial (DCGC01) has proved that D2+CME could improve the surgical and oncological outcomes simultaneously. The systematic lymphatic dissection and proximal mesogastrium resection could be completed in one envelop structure. These results are consistent with those of CME/TME in colorectal surgery.
Objective: To evaluate oncological outcome of locally advanced gastric cancer (AGC) patients receiving D2+CME vs conventional D2 laparoscopic distal gastrectomy.
Methodology: This is a single-center, parallel RCT conducted as a superiority study in to evaluate the superiority of D2+CME procedure in patients with locally AGC. Between September 2014 and June 2018, 486 patients with stage cT2-4N0-3M0 gastric cancer were enrolled in the Department of Gastrointestinal Surgery, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China. Patients were randomly assigned (1:1) to receive either conventional D2 or D2+CME procedure. The modified intention-to-treat (mITT) population was defined as those pathologically diagnosed with gastric adenocarcinoma with pT1N1-3M0 or pT2-4N0-3M0 was used in final analysis. Prognosis was evaluated using overall survival and disease-free survival analyses, with statistical significance assessed by the log-rank test and Gehan–Breslow–Wilcoxon test.
Results: 169 patients in the D2 group and 169 patients in the D2+CME group were included in the mITT analysis. All participants completed the 5-year follow-up period. The recurrence occurred with 53 patients in D2 group (31.4%) and 37 patients in D2+CME group (21.9%) (p=0.049). The 5-year OS rate was 72.8% (95% CI: 66.1%-79.5%) in the D2 group and 79.1% (95% CI: 72.8%-85.4%) in the D2+CME group (Gehan-Breslow-Wilcoxon p=0.047, Log-rank test p=0.052). The 5-year DFS rate was 68.9% (95% CI: 61.9%-75.9%) in the D2 group and 77.8% (95% CI: 71.5%-84.1%) in the D2+CME group (Gehan-Breslow-Wilcoxon test p=0.037, Log-rank test p=0.043). The HR for recurrence in D2+CME group versus D2 group was 0.637 (95% Cl, 0.411-0.990) by Cox regression (p= 0.045). Subgroup analyses showed that among patients with pathological stageⅢ, 5-year disease-free survival rate was 48.2% (95% Cl, 37.0%–59.4%) in the D2 group and 61.2% (95% Cl 48.3%–74.1%) in the D2+CME group (Gehan-Breslow-Wilcoxon test p=0.041,log-rank p=0.065).
Conclusions: D2+CME shows favorable oncological outcome in the surgical treatment of locally AGC.
Keywords: D2+CME, locally AGC, 5-year survival, DCGC01 trial
31. NM23 Expression During Gastric Carcinoma Progression and Its Suppressive Effect on Peritoneal Dissemination
Authors: Na Liang; Qiang Xu; Xiaorong Yang; Dan Yuan; Chuanlou Jin; Qian Liu; Xiaofen Xie; Yue Han; Yi Zhao; Di Wu; Cheng Yang; Jiawei Yang*; Chunming Li*
Affiliation: Zunyi Medical University
Introduction: Peritoneal dissemination is the predominant metastatic pattern and a major cause of poor prognosis in advanced gastric carcinoma. Although NM23 (NME1) is a well-recognized metastasis suppressor, its expression pattern during gastric carcinoma progression and its role in peritoneal dissemination remain incompletely understood. This study aimed to investigate the expression of NM23 during gastric carcinoma progression and to validate its suppressive effect on peritoneal dissemination.
Objective: To investigate the expression pattern of NM23 during gastric carcinoma progression and to evaluate the suppressive effect of NM23 overexpression on peritoneal dissemination using human tissue specimens and an intraperitoneal mouse model.
Methodology: Immunohistochemistry (IHC) was performed to evaluate the expression of NM23, E-cadherin, and N-cadherin in normal gastric mucosa obtained from individuals without gastric neoplasia, gastric intraepithelial neoplasia, early gastric carcinoma, moderately to well-differentiated advanced gastric carcinoma, and poorly differentiated advanced gastric carcinoma (n = 20 per group). Overexpression NM23 in BGC-823 gastric carcinoma cells were established using an adenoviral vector and inoculated into BALB/c nude mice to establish an intraperitoneal dissemination model. At the study endpoint, intraperitoneal tumor burden was assessed by high-frequency ultrasound and confirmed by gross pathological examination. Tumor weight, peritoneal dissemination, ascites formation, and the expression of NM23 and Ki67 in xenograft tumors were further evaluated by IHC and western blotting.
Results: NM23 expression differed significantly among the various stages of gastric lesions (P < 0.05). The positive expression rate of NM23 decreased from 70.0% in normal gastric mucosa to 66.7% in gastric intraepithelial neoplasia, 61.1% in early gastric carcinoma, 47.4% in moderately to well-differentiated advanced gastric carcinoma, and 23.5% in poorly differentiated advanced gastric carcinoma. Reduced NM23 expression was accompanied by decreased E-cadherin and increased N-cadherin expression. In vivo, NM23 overexpression markedly suppressed peritoneal dissemination. Compared with both control groups, NM23-overexpressing mice exhibited reduced intraperitoneal tumor burden, fewer peritoneal metastatic nodules, and less ascites formation. Tumor weight was significantly reduced in the NM23-OE group compared with the Ctrl and NC groups (0.04 ± 0.01 g vs. 0.16 ± 0.02 g and 0.14 ± 0.02 g, respectively; P < 0.05), with a tumor inhibition rate of 75%. High-frequency ultrasound findings were consistent with gross pathological observations. IHC and western blot analyses further confirmed significantly increased NM23 expression in xenograft tumors (IHC: 93.83 ± 3.98 × 10⁴ vs. 17.00 ± 4.38 × 10⁴ and 12.17 ± 2.40 × 10⁴; western blot: 1.33 ± 0.12 vs. 0.52 ± 0.17 and 0.47 ± 0.16; all P < 0.05), whereas the Ki67 proliferation index was significantly reduced (47.83 ± 7.00% vs. 78.17 ± 3.66% and 81.83 ± 4.36%, P < 0.05). NM23 expression was negatively correlated with Ki67 expression (r = −0.87, P < 0.05).
Conclusions: Reduced NM23 expression is associated with the pathological progression of gastric carcinoma. Experimental overexpression of NM23 significantly suppresses peritoneal dissemination and tumor growth while reducing tumor cell proliferative activity, supporting NM23 as an important metastasis suppressor and a potential biomarker for gastric carcinoma progression and peritoneal dissemination.
Keywords: Gastric carcinomaNM23 (NME1)Peritoneal disseminationTumor progressionMetastasis
32. Textbook Outcomes and Textbook Oncological Outcomes in Patients Undergoing Gastrectomy for Gastric Cancer at a Tertiary Referral Center Between 2023 and 2025
Authors: Radoslaw Pach, Marek Sierzega, Miroslaw Szynkarenko, Piotr Richter
Affiliation: First Department of Surgery, Jagiellonian University, Cracow, Poland
Introduction: Textbook outcomes (TO) and textbook oncological outcomes (TOO) are composite quality measures associated with improved prognosis following gastrectomy for gastric cancer.
Objective: This study aimed to evaluate real-world outcomes of patients undergoing gastrectomy for gastric cancer at a tertiary referral center and to assess the quality of multidisciplinary care using TO and TOO.
Methodology: Patients who underwent gastrectomy for gastric cancer between 2023 and 2025 were retrospectively analyzed. TO was defined as achievement of all of the following: R0 resection, retrieval of more than 15 lymph nodes, absence of intraoperative complications, no severe postoperative complications (Clavien–Dindo grade ≥ IIIa), no prolonged hospital stay (>21 days), no reinterventions, no unplanned intensive care unit admission, and no readmission or postoperative mortality within 30 days after surgery. TOO was defined as achievement of TO together with receipt of guideline-recommended perioperative chemotherapy (preoperative and/or postoperative).
Results: A total of 176 patients were included, comprising 66 women and 110 men. The median age was 67 years, and the median length of hospital stay was 9 days. Elective surgery was performed in 94% of patients. Total gastrectomy was the most commonly performed procedure (66.5%), followed by distal gastrectomy (22.2%), proximal gastrectomy (8.0%), and proximal gastrectomy with double-tract reconstruction (2.8%). Most procedures were performed using an open approach (90.3%), while 4.5% were laparoscopic and 5.0% were robotic.An R0 resection was achieved in 76.1% of patients, with a median lymph node yield of 35. Preoperative FLOT chemotherapy was administered to 58.5% of patients, and 64.2% completed postoperative chemotherapy. Overall, 54% of patients achieved TO, while 42% achieved TOO. Among patients who did not achieve TOO, the principal reasons were urgent surgery for bleeding or gastric outlet obstruction and failure to complete perioperative chemotherapy because of treatment intolerance.
Conclusions: Textbook outcomes and textbook oncological outcomes provide meaningful benchmarks for evaluating the quality of surgical and multidisciplinary care in gastric cancer. Although TO and TOO were achieved in a substantial proportion of patients, emergency presentation and inability to complete perioperative chemotherapy remained the major barriers, representing important targets for future quality improvement initiatives.
Keywords: textbook outcomes (TO); textbook oncological outcomes (TOO); gastric cancer; perioperative chemotherapy, Clavien-Dindo classification
33. Peritoneal Carcinomatosis Detection Using a Computed Tomography-based Radiomics Model: Preliminary Results
Authors: Biying Huang, Konstantinos Vrettos, Ivan Moberg, Michail Klontzas, Antonios Tzortzakakis, Ioannis Rouvelas
Affiliation: Department of Clinical Science, Intervention and Technology, Karolinska Institutet, and Centre for Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden
Introduction: Peritoneal carcinomatosis (PC) in gastric cancer is associated with a poor prognosis and its identification can significantly impact treatment planning and patient outcomes. Current non-invasive diagnostic tools such as computed tomography (CT) have limitations in accuracy and efficiency, which is why staging laparoscopy remains the gold standard for diagnosis. Radiomics, an AI-driven approach that extracts quantitative features from medical images, holds promise for improving the detection of PC.
Objective: The aim of this study was to develop an open-access radiomics model to assist radiologists in identifying PC on CT scans, while maintaining human accountability and ethical oversight.
Methodology: The model architecture was based on an attention-based Multiple Instance Learning (MIL) network. The dataset included 141 patients with gastric adenocarcinoma who underwent both CT scanning and staging laparoscopy at the time of diagnosis. Radiomics features were extracted from CT images for 13 regions of the peritoneum corresponding to the Peritoneal Cancer Index (PCI) score. Feature selection was performed with Boruta. The model’s performance was evaluated using AUC, Accuracy, F1-score, Sensitivity, and Specificity on a held-out test set.
Results: The radiomics model achieved an AUC of 0.7, an accuracy of 0.81, and a specificity of 0.94. The model’s performance was also compared with radiologists’ predictions of PC from CT scans, showing that the radiomics deep learning model was non-inferior to expert readers. The human-in-the-loop approach yielded comparable results, with an increased sensitivity of 0.8 when radiologist performance was combined with model performance.
Conclusions: This study highlights the potential of radiomics-based models to improve the detection of PC on CT scans. It further shows that radiologist-AI collaboration can improve detection performance while ensuring transparency, despite limitations such as the relatively small dataset and the lack of prospective evaluation.
Keywords: Peritoneal carcinomatosis, detection, radiomics, computed tomography.
34. Minimally invasive treatment of locally advanced gastric cancer: laparoscopic gastrectomy with prophylactic HIPEC
Authors: A Sikarske, M. Kiudelis, A. Mickevicius, R. Gudaityte, A. Maleckas, Z. Dambrauskas
Affiliation: Department of Surgery, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Kaunas, Lithuania
Introduction: The prognosis for patients with locally advanced gastric cancer (specifically pT3–T4 and node-positive disease) remains highly unfavorable, as radical surgical resection frequently results in peritoneal recurrence rates ranging from 10% to 54% despite achieving clear margins. A growing body of evidence from demonstrates that prophylactic HIPEC can reduce the risk of isolated peritoneal metastasis by approximately 75% (OR: 0.22). Consequently, incorporating prophylactic HIPEC at the time of surgery for patients with locally advanced tumors or minimal peritoneal seeding has been shown to significantly extend 3-year DFS from 61.2% to 73.8% without a prohibitive increase in major postoperative complications. But most of the data comes from the Asian countries, thus we explore the concept in the context of Caucasian population.
Objective: To assess the safety and oncological outcomes of laparoscopic gastrectomy with prophylactic HIPEC for locally advanced gastric cancer
Methodology: This is a review of the clinical data from the first consecutive series of patients who underwent surgery with curative or prophylactic HIPEC for the locally advanced gastric cancer from 2020 to 2025 in the Department of Surgery, Hospital of the Lithuanian University of Health Sciences, Kaunas Clinics. HIPEC duration was 90 min, temperatures 41.5-42.5C, with cisplatin + mitomycin. Data reflecting main patient characteristics, tumor stage, type of surgery and perioperative outcomes within first 60 days was prospectively collected for the analysis. Significant morbidity was classified as Clavien-Dindo ≥ Grade 3.
Results: In total 139 patients had surgery with HIPEC: 95 patients in standard indication group (pseudomyxoma peritonei, mesothelioma, primary peritoneal serous carcinoma, recurrent ovarian cancer, and recurrent colorectal cancer), and 44 patients in locally advanced gastric cancer group.Gastric cancer group: 57% male, mean age 50 (21-70), mean BMI 23, ECOG 0, ASA 3, 33% patients had known comorbidities, PCI 3 (0-11), 50% had peritoneal carcinomatosis outside stomach, stage 3a-4. 24 (55%) out of 44 patients had laparoscopic surgery. Primary surgery in 33 (75%) cases, 11 (25%) second look for local recurrence. In 22% cases extended surgery with multivisceral resections. Median OR time 6h, LOS 12 days, ICU 2 patients, 60 day mortality – 1 patient. HIPEC was performed with prophylactic (55%), curative (36%), and palliative (9%) intent. Survival outcomes differed between the prophylactic and curative HIPEC groups. Median disease-free survival (DFS) was 27 months in the prophylactic group versus 16 months in the curative group, while median overall survival (OS) was 36 and 30 months, respectively. For the entire gastric cancer cohort, median DFS and OS were 27 and 33 months, respectively.
Conclusions: Prophylactic HIPEC administered to patients with locally advanced disease (T3-4 node-positive) before gross carcinomatosis develops – offers a highly substantial survival advantage compared to curative HIPEC performed for existing, limited carcinomatosis. Despite a highly complex patient population (stage IIIa–IV disease, a high baseline burden with an average ASA score of 3, and 33% presenting with known comorbidities), the combination of minimally invasive surgical approach and HIPEC proved safe and reproducible
Keywords: Gastric cancer; Hyperthermic intraperitoneal chemotherapy (HIPEC); Laparoscopic gastrectomy; Peritoneal metastasis; Prophylactic HIPEC
35. Should the Hepatic Branch of the Anterior Vagus Nerve Be Preserved During Adult Fundoplication? A Structured Narrative Review of Biliary Outcomes
Authors: Bruno Matos Santos, Hassan Youssef, Alexis Poirier, Mickael Chevallay, Stefan Mönig
Affiliation: HUG, University Hospital of Geneva
Introduction: Division of the hepatic branch of the anterior vagus nerve during laparoscopic fundoplication can facilitate hiatal exposure, but may also alter gallbladder motility and biliary physiology. Despite long-standing anatomical and physiological interest, the clinical relevance of routine branch preservation remains uncertain.
Objective: Our objective is to synthesize the evidence on hepatic branch identification, preservation, and division during adult fundoplication, with specific attention to gallbladder function and postoperative biliary outcomes.
Methodology: We conducted a structured review informed by a systematic search of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) from 1 January 1970 to 31 March 2026. The search and selection process followed PRISMA 2020 principles, and the narrative synthesis was structured according to SANRA. Evidence was synthesized across four domains: anatomy, operative identification and preservation, fundoplication-specific physiological and clinical outcomes, and supportive evidence from vagotomy and vagus-preserving upper gastrointestinal surgery.
Results: The search identified 847 records. After deduplication and screening, 63 full-text articles were assessed. Three fundoplication studies were retained as direct or near-direct evidence, including two studies comparing hepatic branch preservation with division and one pre-/post-fundoplication study of gallbladder function (cumulative n = 97). Supportive mechanistic and translational evidence was considered separately. In the randomized trial by Ozdogan et al., hepatic branch division prolonged gallbladder emptying time, whereas fasting volume and ejection fraction were unchanged. Purdy et al. reported lower fasting gallbladder volume and higher plasma amylase after division at long-term follow-up, without clear symptomatic biliary morbidity. Morton et al. found no consistent short-term association. Evidence from vagotomy, gastrectomy, and bariatric surgery supports biological plausibility, but cannot be directly extrapolated to fundoplication.
Conclusions: Identification and preservation of the hepatic branch during adult fundoplication is technically feasible and physiologically plausible. However, direct comparative evidence remains limited to small studies with mostly surrogate motility endpoints, and a reduction in symptomatic biliary events has not been demonstrated. Current evidence supports selective preservation when the branch is clearly identifiable and exposure is not compromised, together with systematic documentation of branch status in operative reports.
Keywords: Vagus Nerve; Fundoplication; Laparoscopy; Gallbladder Emptying; Biliary Tract Physiology; Postoperative Complications; Upper Gastrointestinal Surgery.
36. Prospective Single-Cohort Study of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in Gastric Cancer
Authors: Dobrzhanskyi O., Pepenin M., Kolesnyk A., Turchak V., Khyduntsev A., Shudrak Y., Vygovskyi N., Horodetskyi A.
Affiliation: Upper gastrointestinal oncology department, National Cancer Institute, Kyiv, Ukraine
Introduction: Local or distant tumour extension may lead to treatment failure in gastric cancer, and patients with peritoneal involvement or positive peritoneal cytology have a poor prognosis with systemic therapy alone. Hyperthermic intraperitoneal chemotherapy (HIPEC) combined with radical gastrectomy or cytoreductive surgery may improve oncological outcomes in carefully selected patients. We evaluated long-term survival and surgical safety of HIPEC as part of multimodal treatment for locally advanced gastric cancer.
Objective: The main objective is to evaluated long-term survival and surgical safety of HIPEC as part of multimodal treatment for locally advanced gastric cancer.
Methodology: This is a preliminary analysis of an ongoing, prospectively registered observational single-centre cohort study (ClinicalTrials.gov NCT07313579; G-PEC trial). At the data cut-off, 41 patients with a mean age of 56.5 years (SD 11.6; range 22–77) with locally advanced or metastatic gastric cancer had been enrolled. ECOG performance status was 0 in 30 patients (73%) and 1 in 11 (27%). The primary tumour was located in the gastric body in 22 patients (54%), the cardia/gastro-oesophageal junction in 7 (17%), the antrum in 6 (15%), and was multifocal or involved the whole stomach in 6 (15%). Twelve patients (29%) had macroscopic peritoneal carcinomatosis and 14 (34%) had positive peritoneal cytology (cyt+) before chemotherapy. Indications for HIPEC (frequently overlapping) were serosal invasion (T4a) in 20 patients (49%), macroscopic peritoneal carcinomatosis in 12 (29%), positive peritoneal cytology in 6 (15%), and T4b disease in 4 patients (10%). Patients received neoadjuvant chemotherapy (predominantly FLOT), followed by surgery and HIPEC (mitomycin C plus cisplatin, 60 minutes). Curative-intent total gastrectomy with D2 lymphadenectomy was performed in 39 patients (95%); 2 patients (5%) with unresectable disease underwent cytoreduction/palliative surgery with HIPEC. The primary endpoint was 3-year overall survival (OS) from the date of surgery; secondary endpoints were 3-year disease-free survival (DFS) and the rate of surgical complications graded by the Clavien–Dindo classification. Survival was estimated using the Kaplan–Meier method with 95% confidence intervals (CI).
Results: R0 resection was achieved in 38 of 41 patients (93%). Postoperative surgical complications occurred in 10 patients (24%); major complications (Clavien–Dindo ≥ IIIa) were recorded in 4 patients (10%), comprising para-anastomotic abscess, exudative pleuritis, mixed small–large bowel obstruction, and subhepatic abscess with anastomotic leak. At a median follow-up of 24 months, the 3-year overall survival from the date of surgery was 59% (95% CI 38–75) and the 3-year disease-free survival was 52% (95% CI 32–69).
Conclusions: HIPEC combined with radical surgery in the multimodal treatment of locally advanced gastric cancer is surgically safe, with a major complication rate of 10%, and is associated with encouraging 3-year survival in selected patients. As a preliminary analysis of an ongoing registered cohort study (NCT07313579), these findings are hypothesis-generating; mature survival data with longer follow-up and the full planned sample are awaited to confirm the role of HIPEC in this setting.
Keywords: gastric cancer; HIPEC; cytoreductive surgery; peritoneal carcinomatosis; overall survival; Clavien–Dindo.
37. Dynamic peripheral immune remodeling during neoadjuvant chemotherapy is associated with pathological response in locally advanced gastric cancer
Authors: Presenting Author: Chiara Molinari. Authors: R. H. Camara1, J. Bulgarelli1,*, E. Petracci1, D. Prascevic2, F. Rebuzzi1, V. Kokala Dimitropoulou3, M. Monti1, P. Morgagni4, M. Valgiusti1, L. Solaini4,5, G. N. Sabatino1, J. Ewald2, P. Ulivi1, A. Passardi1, S. Tamberi5,6, G. Arbore7, L. Saragoni5,8, G. Ercolani4,5, M.M. Konstadoulakis3, L. Corcos9, A. Derventzi10,# and C. Molinari1,#
Affiliation: 1IRST „Dino Amadori”, Italy 2ScaDS.AI, Leipzig University, Germany 32nd Surgery, NKUA, Greece 4 Surgery, Morgagni-Pierantoni Hospital, Forlì, Italy 5DIMEC, University of Bologna, Italy 6 Oncology, S Maria delle Croci Hospital, Italy 7Vita-Salute San Raffaele University, Italy 8Pathology, Santa Maria delle Croci Hospital, Italy 9University Brest, France 10Prop Surgery, NKUA, Greece
Introduction: Neoadjuvant chemotherapy (NCT) followed by surgery remains the backbone of treatment for locally advanced gastric cancer (LAGC), while emerging immunotherapy-based combinations are reshaping the therapeutic landscape and may further improve pathological response rates. However, response to neoadjuvant treatment remains highly heterogeneous, and reliable biomarkers for predicting therapeutic benefit are still lacking. While tumor-intrinsic features have been extensively investigated, the contribution of the peripheral immune landscape to treatment response remains poorly defined.
Objective: This study aimed to characterize pre- and post-treatment peripheral immune profiles and identify immune features associated with pathological response to NCT in patients with LAGC.
Methodology: Peripheral blood samples were prospectively collected before and after NCT from 33 patients with LAGC undergoing curative-intent surgery. Patients were mainly treated with FLOT-based chemotherapy (88%). Peripheral blood mononuclear cells (PBMCs) were analyzed by multiparametric flow cytometry, together with serum cytokine assessment (IL-2, IL-4, IL-6, IL-10, IL-17A, IFNγ, TNF-α). Immune compartments including monocytes, myeloid-derived suppressor cells (MDSCs), CD4⁺ and CD8⁺ T cells, regulatory T cells, and NK/NKT-like cells were characterized according to frequency, differentiation, and activation status. Exhausted immune subsets were defined by the expression of inhibitory receptors (PD-1, TIM-3, LAG-3, TIGIT, and CTLA-4). Associations between immune features and pathological response were evaluated according to Tumor Regression Grade (TRG) and ypT stage after NCT.
Results: Lower response rates were observed in female patients and in those with lower body mass index. Pathological response was associated with treatment-induced changes in T-cell differentiation profiles, with responders showing a favorable balance between naïve and differentiated CD4⁺ and CD8⁺ T-cell subsets. A distinct immune trajectory was observed in patients achieving complete regression of the primary tumor (ypT0), characterized by an increase in circulating CD8⁺ T cells and a concomitant decrease in neutrophils after NCT. Higher NK-cell levels were associated with major pathological response, whereas exhausted NK phenotypes correlated with poor response and residual lymph node involvement after treatment. Responders displayed lower baseline levels of TNF-α, IL-6, and IL-4. Higher baseline terminally differentiated effector memory CD4⁺ T cells were associated with poor response, whereas central memory CD4⁺ T cells and higher eMDSC/CD8⁺ T-cell ratio were associated with improved pathological response.
Conclusions: Pathological response to NCT in LAGC is associated with a competent peripheral immune profile and dynamic immune remodeling during treatment. Conversely, non-responders display features of immune dysfunction and exhaustion. Peripheral immune profiling may represent a promising strategy for patient stratification and optimization of multimodal treatment approaches in LAGC. [Study supported by Italian Ministry of Health within the Transcan-3 JTC 2021 project PREDICO (ERP-2021-23682558)].
Keywords: Locally Advanced Gastric Cancer, Neoadjuvant Therapy, Pathological Response, Peripheral Blood Mononuclear Cells, Cytokines, Natural Killer, T-Lymphocytes, Exhausted immune Cells
38. Laparoscopic versus robotic gastrectomy for gastric cancer: a multicenter matched analysis of short- and long-term outcomes from the Italian Research Group on Gastric Cancer (GIRCG) registry
Authors: Ludovico Carbone 1, Daniele Marrelli 1,2, Elio Treppiedi 3, Ugo Elmore 3, Laura Fortuna 4, Flavia Carlini 5, Chiara Togni 6, Michele Di Marino 7, Marco Milone 8, Federica Filippini 9, Marina Valente 10, Giorgio Dalmonte 10, Leonardo Solaini 11, Stefano De Pascale 12, Pietro Maria Lombardi 13, Silvia Ministrini 14, Manuela Robella 15, Arcangelo Picciariello 16, Luigina Graziosi 17, Rossella Reddavid 18, Samantha Vellei 19, Manrica Fabbi 20, Stefano Rausei 20, Aurora Visani 1, Annibale Donini 17, Leonardo Vincenti 16, Felice Borghi 15, Guido Alberto Tiberio 14, Giovanni Ferrari 13, Uberto Fumagalli Romario 12, Paolo Morgagni 11, Giorgio Ercolani 11, Federico Coccolini 10, Simone Giacopuzzi 9, Andrea Coratti 7, Gianluca Garulli 6, Giovanni Camerini 5, Fabio Cianchi 4, Riccardo Rosati 3, Giovanni De Manzoni 9, Franco Roviello 1,2 1 University of Siena2 Azienda Ospedialiero Universitaria Senese in Siena3 San Raffaele Hospital in Milan4 University of Florence5 Hospital San Martino in Genova6 Hospital Infermi in Rimini7 Hospital Misericordia in Grosseto8 University of Neaples9 University of Verone10 University of Parma11 Hospital Morgagni Pierantoni in Forlì12 Istituto Europeo di Oncologia in Milan13 Hospital Niguarda in Milan14 University of Brescia15 Candiolo Cancer Institute16 University of Lecce17 University of Perugia18 Hospital San Luigi Gonzaga in Turin19 Hospital Santo Stefano in Prato20 Hospital Cittiglio Sette Laghi
Affiliation: University of Siena
Introduction: Robotic surgery is becoming increasingly popular for treating gastric cancer, but it remains unclear whether it truly improves outcomes compared with laparoscopy in Western patients.
Objective: We used a large Italian multicenter registry to compare short- and long-term outcomes between the two approaches.
Methodology: Adult patients undergoing minimally-invasive distal or total gastrectomy in Italy were identified (2015–2025, n=996) and matched by inverse probability of treatment weighting (IPTW) into weighted laparoscopic (wLG) and robotic (wRG) groups (311 per arm) for perioperative outcomes. Long-term outcomes were assessed in a subset with a minimum 3-year follow-up (2015–2022, n=487; 104 per arm after matching).
Results: Postoperative complications and early mortality were comparable between wLG and wRG (21.9% vs. 16.1%, P=0.066; 2.2% vs. 2.6%, P=0.412), with no independent predictors of major complications by surgical approach. Total lymph node retrieved trended lower after laparoscopy (median 32 vs. 36, P=0.053), and subgroup analysis revealed significantly higher extragastric lymph node retrieval after robotic surgery (P<0.001). At long-term follow-up, 5-year overall survival reached 79.6% after wLG versus 68.4% after wRG (HR 0.571; P=0.095), with no significant survival predictors identified in either group. Disease-free survival and distribution of recurrence sites were similar between approaches.
Conclusions: Robotic and laparoscopic gastrectomy achieved comparable perioperative safety and long-term oncological outcomes after adjustment for baseline imbalances, when performed in specialized centers. These findings support both platforms as valuable options and position robotic surgery as a scalable alternative to laparoscopy in Western gastric cancer care.
Keywords: laparoscopic; robotic; gastrectomy; complications; lymph nodes; textbook outcome; survival; recurrence.
39. Total neoadjuvant FLOT chemotherapy in cT4a versus cT4b gastric and gastroesophageal junction cancer
Authors: Dobrzhanskyi O., Horodetskyi A., Pepenin M., Kondratskyi Y.
Affiliation: Department of Upper Gastrointestinal Oncology, National Cancer Institute, Kyiv, Ukraine
Introduction: Total neoadjuvant chemotherapy (TNT) with FLOT delivers all planned chemotherapy before surgery in locally advanced gastric and gastroesophageal junction (GEJ) cancer. Whether the depth of baseline tumour invasion (cT4a vs cT4b) affects treatment delivery, pathological response, and surgical outcomes is not well defined.
Objective: To compare chemotherapy delivery, toxicity, pathological response, and postoperative outcomes of TNT-FLOT between patients with cT4a and cT4b tumours.
Methodology: Retrospective single-centre cohort (National Cancer Institute, Kyiv; October 2017 to October 2021). Among patients with clinical T4 disease, 36 with cT4a and 16 with cT4b tumours received eight planned cycles of neoadjuvant FLOT followed by curative surgery. Categorical variables were compared by χ² or Fisher’s exact test and continuous variables by Mann–Whitney U; a two-sided p<0.05 was considered significant.
Results: Baseline demographics, ECOG status, histology, tumour location, nodal stage, and grade were comparable between groups. Median FLOT cycles delivered were 8 (IQR 7–8) versus 7 (6–8) (p=0.27), and completion of all eight cycles 63.9% versus 37.5% (p=0.13); dose reductions were required more often in cT4b (81.3% vs 38.9%, p=0.007), although grade 3–4 toxicities did not differ. Multivisceral resection was far more frequent in cT4b (81.3% vs 8.3%, p<0.001), yet R0 resection (87.5% vs 94.4%, p=0.58), any-grade complications (62.5% vs 66.7%), major complications (37.5% vs 30.6%), and 30- and 90-day mortality did not differ. Pathologically, cT4b tumours showed less primary-tumour downstaging (residual ypT4b 43.8% vs 5.6%; overall ypT distribution p=0.028) and more lymphovascular invasion (93.8% vs 66.7%, p=0.044); nodal stage and Becker regression grade were similar.
Conclusions: TNT-FLOT was deliverable across the T4 spectrum with comparable toxicity, R0 rate, morbidity, and mortality, even though cT4b tumours required more dose reductions and multivisceral resection. However, cT4b disease showed less primary-tumour downstaging and more lymphovascular invasion, indicating more adverse residual biology and supporting stratified treatment strategies. As a retrospective single-centre subgroup analysis, these findings are exploratory and hypothesis-generating.
Keywords: gastric cancer; gastroesophageal junction; total neoadjuvant chemotherapy; FLOT; T4 stage; pathological response
40. Baseline peritoneal disease and recurrence after gastrectomy with HIPEC in gastric cancer
Authors: Dobrzhanskyi O., Pepenin M., Kolesnyk A., Horodetskyi A., Turchak V., Khyduntsev A.
Affiliation: Upper gastrointestinal oncology department, National Cancer Institute, Kyiv, Ukraine
Introduction: HIPEC is added to gastrectomy to control peritoneal disease in gastric cancer, and is used both prophylactically for serosal (T4) tumours and therapeutically for macroscopic carcinomatosis or positive peritoneal cytology. Whether HIPEC offsets the adverse prognosis conferred by established peritoneal disease is uncertain.
Objective: To compare recurrence after gastrectomy with HIPEC between patients with and without baseline peritoneal disease, defined as macroscopic carcinomatosis or positive peritoneal cytology.
Methodology: Preliminary analysis of a prospectively registered single-centre cohort (ClinicalTrials.gov NCT07313579). Forty-three patients received neoadjuvant chemotherapy (predominantly FLOT), gastrectomy, and HIPEC (mitomycin C + cisplatin; 60 minutes in 37 patients, 90 minutes in 5). Baseline peritoneal disease was defined as macroscopic carcinomatosis (any Peritoneal Cancer Index) and/or positive peritoneal cytology at laparoscopy. Recurrence (clinical or radiological progression) was compared between groups using Fisher’s exact test; proportions are reported with Wilson 95% confidence intervals.
Results: Of 40 patients with evaluable peritoneal status, 20 (50%, 95% CI 35–65) had baseline peritoneal disease — macroscopic carcinomatosis in 12 and positive cytology in 14 (overlap 6) — with low quantified burden (median PCI 1, range 1–27). Complete (R0) resection was achieved in all evaluable patients in this group (19/19). With recurrence status available for 29 patients, recurrence was numerically higher in the peritoneal-disease group than in those without peritoneal disease (8/14, 57% vs 4/15, 27%; odds ratio 3.67), but the difference was not statistically significant (Fisher p=0.14); at least two recurrences were documented as peritoneal carcinomatosis.
Conclusions: Gastrectomy with HIPEC and complete cytoreduction was achievable even in patients with macroscopic carcinomatosis or positive cytology. Nonetheless, baseline peritoneal disease was associated with a two-fold, though non-significant, trend toward higher recurrence, suggesting that HIPEC does not fully neutralise the risk conferred by established peritoneal involvement. As a single-arm preliminary analysis with incomplete recurrence data, these findings are exploratory and warrant larger, controlled evaluation.
Keywords: gastric cancer; HIPEC; peritoneal carcinomatosis; peritoneal cytology; recurrence; cytoreductive surgery
41. Overall survival and prognostic factors after PIPAC for gastric peritoneal metastases
Authors: Andrii Horodetskyi, Mykyta Pepenin, Oleksii Dobrzhanskyi
Affiliation: Upper Gastrointestinal Oncology department, National Cancer Institute, Ukraine
Introduction: Peritoneal metastasis from gastric cancer carries a poor prognosis, and the role of PIPAC — particularly in heavily pretreated or high-burden disease — is unsettled. It is unclear which baseline or on-treatment factors identify patients who benefit, and whether tumour burden or treatment line should guide selection.
Objective: To describe overall survival (OS) after bidirectional PIPAC in a gastric-only cohort and its association with treatment line, peritoneal burden, and radiologic/histologic response.
Methodology: Single-centre retrospective/ambispective cohort; 30 patients with gastric peritoneal metastases treated with bidirectional PIPAC (cisplatin + doxorubicin, median 3 procedures) plus systemic chemotherapy. OS was measured from first PIPAC (Kaplan–Meier, log-rank); median follow-up by reverse Kaplan–Meier. Prespecified subgroups: prior chemotherapy line (1st/2nd/3rd+), baseline PCI (<7, 7–15, >15), PCI response, and PRGS response.
Results: PIPAC was consistently deliverable (12 mmHg / 30 min; no procedural aborts). With 24 deaths and median follow-up 17.6 months, median OS was 8.7 months (95% CI 5.4–11.5); OS was 63%, 21% and 8% at 6, 12 and 24 months. Survival did not differ by line of therapy (1st n=5, 2nd n=10, 3rd+ n=15; p=0.84) or baseline PCI burden (p=0.78); histologic response was likewise preserved across lines (PRGS response 80%, 90%, 100% for 1st/2nd/3rd+). Macroscopic PCI response was not associated with OS (p=0.48). PRGS response was strongly associated with longer OS (responder n=24 vs non-responder n=6; p<0.001); however, this is subject to guarantee-time bias, as responders by definition survived long enough for repeat biopsy. Prior gastrectomy was associated with better OS (p=0.022) in a small subgroup (n=6).
Conclusions: Median OS approached 9 months in this predominantly diffuse-type, heavily pretreated cohort, and PIPAC was safely delivered across all treatment lines. Neither peritoneal burden nor line of therapy stratified survival, arguing against their use to exclude patients from PIPAC. The apparent survival advantage of histologic responders should not be interpreted causally, given guarantee-time bias and the absence of a control arm.
Keywords: gastric cancer; peritoneal metastases; PIPAC; overall survival; line of therapy; Peritoneal Cancer Index
42. Discordance between histological regression and macroscopic tumour burden after PIPAC for gastric peritoneal metastases
Authors: Mykyta Pepenin, Andrii Horodetskyi, Oleksii Dobrzhanskyi
Affiliation: Upper Gastrointestinal Oncology department, National Cancer Institute, Ukraine
Introduction: Pressurized intraperitoneal aerosol chemotherapy (PIPAC), given with systemic chemotherapy (bidirectional), is increasingly used for gastric-cancer peritoneal metastases. The Peritoneal Regression Grading Score (PRGS) is the standard histologic efficacy endpoint, yet whether histologic regression reflects true macroscopic disease control remains uncertain, and most reported series pool multiple tumour origins.
Objective: In a gastric-only cohort, to quantify histologic (PRGS) and macroscopic (Peritoneal Cancer Index, PCI) response to bidirectional PIPAC and to test their concordance.
Methodology: Single-centre retrospective/ambispective cohort (National Cancer Institute of Ukraine): 40 patients with gastric-primary peritoneal metastases, 116 PIPAC procedures (cisplatin + doxorubicin, 12 mmHg / 30 min), all on concurrent systemic chemotherapy. PRGS response = best on-course PRGS 1–2; complete histologic response (CHR) = best PRGS 1. PCI response = any decrease from baseline to nadir. Proportions used Wilson 95% CIs; paired change the Wilcoxon signed-rank test; per-cycle trajectories linear mixed-effects models; PRGS–PCI agreement Cohen’s κ and repeated-measures correlation.
Results: Median 3 PIPAC per patient (range 1–9); no procedural aborts. Among 27 patients with ≥1 scored biopsy, PRGS response was 25/27 (93%, 95% CI 77–98) and CHR 22/27 (81%, 63–92); where baseline PRGS exceeded 1, regression occurred in 8/11 (73%; paired baseline-to-best p=0.009). PRGS did not deepen across cycles (slope −0.06/cycle, p=0.40), indicating an early floor effect. Macroscopically, PCI did not improve (baseline-to-last p=0.27; slope −0.37/cycle, p=0.18): any-decrease responders 7/29 (24%), ≥25% reduction 2/29 (7%), progression 10/29 (34%). The two endpoints were discordant (κ=0.06; repeated-measures r=+0.15, p=0.42): of 24 dually-assessable patients, 22 were PRGS responders yet only 6 were PCI responders. Results were robust to exclusion of checkpoint-inhibitor and non-standard cases (PRGS 92–93%; PCI 24–27%).
Conclusions: Under bidirectional therapy, most biopsied foci regress while whole-cavity burden is unchanged. Because all patients received concurrent systemic chemotherapy, these changes cannot be attributed to PIPAC alone, and the high PRGS response is conditional on gradeable tissue (13/40 patients ungraded, enriched for residual disease). The PRGS–PCI discordance — partly sampling, partly biology — argues against using histologic response in isolation as an efficacy surrogate for gastric PIPAC.
Keywords: gastric cancer; peritoneal metastases; PIPAC; PRGS; Peritoneal Cancer Index; bidirectional chemotherapy
43. Intraoperative detection of gastric cancer metastases not identified on imaging studies
Authors: Andrzej Roszkowski, Przemysław Galbfach, Wiktoria Godlewska, Marta Podlasińska, Jerzy Czarnecki, Anna Kożuch, Olga Przybyłowska
Affiliation: WSZ w Plocku Kliniczny Oddzial Chirurgii Ogolnej i Onkologicznej
Introduction: Gastric cancer is the fifth most common cancer in terms of incidence and mortality. Worldwide, approximately 1,000,000 people are diagnosed with it each year, of whom about 68% die. Gastric cancer is quite aggressive; in about 35% of cases, metastases are present at the time of diagnosis.Currently, computer tomography (CT) is the standard for pre- and postoperative diagnosis.
Objective: Case report
Methodology: Case report
Results: We present the case of a patient who underwent gastric resection for cancer 4 years ago. Until admission to the ward, the patient remained under the care of the Oncology Clinic. The patient was admitted to the ward due to high gastrointestinal obstruction. Imaging studies did not indicate progression of the cancer. It was decided to perform a laparotomy, during which spread of gastric cancer to the peritoneal cavity was confirmed.
Conclusions: Despite advanced imaging techniques, exploratory laparotomy remains the definitive method for assessing the extent of cancer within the abdominal cavity.
Keywords: Gastric cancer, tomography,
44. Surgical outcomes following introduction of the FLOT regimen for resectable gastric adenocarcinoma: a real-world single-centre experience
Authors: Nicolak Lobo Flores; Amalia Pelegrina; Francisco Buils; Javier Menéndez, Manuel Rodriguez; Joan Domenech
Affiliation: Department of General and Digestive Surgery, Hospital Universitari Sant Joan de Reus, Reus, Spain
Introduction: The FLOT regimen has become the standard perioperative treatment for resectable gastric adenocarcinoma after demonstrating superior survival outcomes compared with epirubicin-based regimens. However, it remains of interest to determine how this therapeutic shift has translated into surgical and perioperative outcomes in routine clinical practice
Objective: To compare surgical and perioperative outcomes between patients with resectable gastric adenocarcinoma treated with the FLOT regimen and those treated with the perioperative regimens previously used at our institution
Methodology: We conducted a retrospective single-centre study including patients who underwent curative-intent resection for resectable gastric adenocarcinoma over a seven-year period. Among a cohort of 101 patients, 35 received perioperative chemotherapy: 19 were treated with FLOT and 16 with perioperative regimens previously used at our institution. Clinical, surgical, pathological and postoperative variables were analysed, including surgical approach, postoperative complications according to the Clavien–Dindo classification, length of hospital stay, resection margin status and administration of adjuvant treatment. Statistical analyses were performed using non-parametric tests and Fisher’s exact test. Odds ratios (ORs) with 95% confidence intervals (95% CIs) were calculated
Results: comparable between groups. Patients treated with FLOT had a higher rate of laparoscopic surgery (100% vs. 62.5%; p = 0.005), a shorter hospital stay (7 vs. 9.5 days; p = 0.045), and a clinically relevant reduction in postoperative complications (26.3% vs. 56.3%; OR 0.28, 95% CI 0.07–1.08), although this difference did not reach statistical significance (p = 0.094). The FLOT group also achieved a higher R0 resection rate (100% vs. 81.2%) and a greater likelihood of completing adjuvant treatment (78.9% vs. 43.8%; OR 4.82, 95% CI 1.12–20.7; p = 0.043). No significant differences were observed in recurrence or mortality during follow-up.
Conclusions: In our experience, perioperative treatment with FLOT was associated with a higher use of a laparoscopic approach, shorter postoperative hospital stay and a greater likelihood of completing adjuvant treatment while maintaining high R0 resection rates. Although the reduction in postoperative complications did not reach statistical significance, the magnitude of the observed effect suggests a potentially meaningful clinical benefit that should be confirmed in larger prospective studies
Keywords: Gastric adenocarcinoma; FLOT; Perioperative chemotherapy; Gastrectomy; Surgical outcomes
45. D2 Lymphadenectomy for Gastric Cancer in the Minimally Invasive and Robotic Era: Quality Validation in a 6-Year Series
Authors: Mariaclaudia Ocharan, Candela Lopez, Natalia De La Puente, Irene Vazquez, Aloia Guerreiro, Gisela Navarro, Rocio González, Olga Maseda
Affiliation: General Surgery Resident, Hospital Universitario Lucus Augusti, Lugo, Galicia, Spain
Introduction: D2 lymphadenectomy constitutes the cornerstone of surgical treatment with curative intent for gastric cancer. Reaching or exceeding the threshold of 25 harvested lymph nodes is the international quality standard in lymphadenectomy. Maintaining this oncological yield is currently a challenge due to the increase in tissue fibrosis induced by modern neoadjuvant chemotherapy regimens and the technical difficulties inherent to the transition toward a minimally invasive approach (laparoscopic and robotic).
Objective: To audit the technical quality of oncological gastrectomies at our center, evaluating the systematic compliance with international D2 lymphadenectomy standards throughout our transition toward robotic and minimally invasive surgery.
Methodology: A retrospective observational study of a prospective database (2020–2025) was conducted. Patients who underwent gastrectomy with curative intent for gastric adenocarcinoma were included. Gastrointestinal stromal tumors (GIST), non-adenocarcinomatous histologies, and palliative/exploratory surgeries were excluded. Annual volume, the evolution of the surgical approach, the use of neoadjuvant therapy, and the number of harvested lymph nodes were analyzed. Our protocol requires D2 dissection and station-by-station submission to the Pathology Department.
Results: More than 175 gastric interventions were recorded during the study period, showing a sustained increase in surgical volume (from 26 overall cases in 2020 to an estimated 40 in 2025). After applying the exclusion criteria, a cohort of more than 100 patients with adenocarcinoma was analyzed. The analysis reflects a successful surgical transition: starting from a laparoscopic predominance in 2020 (80%), the department introduced the robotic approach in 2022, resulting in combined robotics and laparoscopy accounting for the vast majority of curative resections in 2023 and 2024. This was achieved in an elderly cohort (mean age >71 years) and with high rates of neoadjuvant therapy. Regarding oncological radicality, nearly 100% of the analyzed surgical specimens exceeded the quality standard, systematically achieving a count of more than 25 lymph nodes, with no decrease in lymph node yield recorded during the laparoscopic and robotic learning curves.
Conclusions: The standardization of D2 lymphadenectomy and meticulous anatomical mapping allow our department to systematically achieve the suggested international standards. The progressive and successful adoption of minimally invasive surgery, including the implementation of the robotic program, does not compromise the radicality of the dissection. Routinely obtaining more than 25 lymph nodes ensures optimal staging, positioning our gastric surgery program within international quality standards.
Keywords: Gastric cancer, D2 lymphadenectomy, Robotic gastrectomy, Lymph node yield, Quality indicators
46. The role of staging laparoscopy in assessing gastric cancer stage and its impact on treatment strategy – a single-center experience
Authors: Katarzyna Jalinik, Monika Bieniasz, Sylwia Betz, Wojciech Kaźmierczak, Wojciech Kwiatkowski, Adam Dmitruk, Łukasz Zyskowski, Piotr Surowski, Leszek Zając, Tomasz Olesiński
Affiliation: Department of Gastrointestinal Cancer Surgery, Maria Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
Introduction: Staging laparoscopy (SL) is a well-established diagnostic tool recommended by the NCCN, ESMO, and SAGES guidelines for the preoperative staging of gastric cancer (GC). As a minimally invasive procedure, SL facilitates the detection of small peritoneal metastatic lesions that may remain undetected on computed tomography (CT).
Objective: To compare disease stage assessed by staging laparoscopy with preoperative radiological staging and to evaluate the usefulness of SL in detecting metastatic disease and its impact on subsequent therapeutic decision-making.
Methodology: A total of 124 patients (age range: 30–83 years; mean age: 64.4 years) with histologically confirmed gastric cancer were included in this retrospective study. The cohort comprised 63 (50.8%) men and 61 (49.2%) women who underwent staging laparoscopy between 2021 and 05.2026 at the Department of Gastrointestinal Cancer Surgery, Maria Skłodowska-Curie National Research Institute of Oncology (NIO-PIB), Warsaw, Poland. Before SL, all patients underwent contrast-enhanced CT of the chest, abdomen, and pelvis for clinical staging.
Results: Peritoneal metastatic disease, including peritoneal and greater omental implants and/or the presence of malignant cells in peritoneal fluid or peritoneal washings, was identified in 29 patients (23.4%). Concordance between CT findings suggestive of metastatic dissemination and SL findings was observed in 13 patients (10.5%). Among patients with CT-based clinical stage T3/T4 disease, SL revealed previously undetected peritoneal dissemination in 26 patients (20.9%). Consequently, the treatment strategy was modified in these 26 patients (20.9%): 19 patients were referred for palliative chemotherapy, while 7 underwent cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) using the closed technique.
Conclusions: Staging laparoscopy is an effective method for detecting peritoneal metastases that remain difficult to identify despite modern radiological imaging techniques. SL significantly influences therapeutic decision-making by preventing unnecessary laparotomy and inappropriate treatment in patients with advanced gastric cancer.
Keywords: Gastric cancer, Staging laparoskopy
47. The operative protocol as the missing link in standardizing gastric cancer surgery in Europe. Proposal of a standardized operative report based on JGCA and ACS Standards – COMPASS-GC (Comprehensive Operative Management Protocol for Advanced Stomach Surgery in Gastric Cancer).
Authors: Kamil Rapacz, Piotr Kołodziejczyk, Piotr Richter
Affiliation: General, Oncological, Gastroenterological and Transplant Surgery Clinical Department, University Hospital in Krakow; Jagiellonian University Medical College
Introduction: Over the past decade, the management of gastric cancer has become increasingly standardized. International guidelines comprehensively define recommendations for diagnosis, patient selection, perioperative therapy, and pathological reporting. In contrast, operative documentation remains largely unstructured and varies considerably among institutions and individual surgeons. Unlike standardized pathology reports, there is currently no widely accepted operative reporting template for gastric cancer surgery in Europe. This lack of standardization limits surgical quality assessment, clinical auditing, and meaningful comparison of outcomes across institutions.
Objective: To develop a standardized operative reporting template for gastric cancer surgery based on internationally recognized quality standards.
Methodology: Current international guidelines and recommendations regarding the quality of gastric cancer surgery were reviewed. The proposed protocol was primarily based on the Japanese Gastric Cancer Association (JGCA) classification of gastrectomy and lymphadenectomy, together with the operative reporting principles recommended by the American College of Surgeons (ACS). Additional elements relevant to contemporary European surgical practice and quality assurance were incorporated to ensure clinical applicability.
Results: A structured operative reporting template (COMPASS-GC) was developed, encompassing all essential components of gastric cancer surgery. The protocol includes documentation of intraoperative abdominal exploration, assessment of peritoneal dissemination, performance of peritoneal cytology, type of gastrectomy, extent of lymphadenectomy according to the JGCA classification, multivisceral resections, evaluation of surgical margins, method of gastrointestinal reconstruction, intraoperative events and complications, and assessment of resection status (R0/R1/R2). The protocol was designed as a checklist to facilitate complete, consistent, and reproducible documentation of surgical procedures.
Conclusions: Despite substantial advances in the standardization of systemic treatment and pathological reporting, operative documentation remains an insufficiently standardized component of gastric cancer care. The proposed COMPASS-GC protocol provides a practical tool for harmonizing operative reporting, facilitating surgical quality assessment, and supporting future multicenter research. Its implementation may improve the completeness and consistency of operative documentation while establishing a foundation for international quality assurance programs in gastric cancer surgery.
Keywords: Gastric cancer; Gastrectomy; Operative report; Operative protocol; Surgical quality; Standardization; Lymphadenectomy
48. Age-Based Stratification and Treatment Selection in Elderly Gastric Cancer Patients: A Real-World Comparison of Upfront Surgery and Neoadjuvant Chemotherapy Cohorts
Authors: Giorgi Lorenzo MD 1, De Martino Renato MD 2,3, Casiraghi Marta MD 2,3, Pansa Andrea MD 1, Alfieri Rita MD 1, Garbarino Giovanni Maria MD PhD 1,2 Basato Silvia MD 1, Castoro Carlo MD 1,2
Affiliation: 1. Upper Gastrointestinal Surgery Unit, IRCCS Humanitas Research Hospital, 20089 Milan, Italy. 2. Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy 3. IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
Introduction: Perioperative chemotherapy is the standard of care for locally advanced gastric cancer, but its role in elderly patients remains debated due to concerns about systemic toxicity, surgical stress, and high adjuvant drop-out rates. In real-world practice, treatment allocation in this population is strongly influenced by clinical judgment regarding frailty and tumor burden, which limits direct comparison between strategies.
Objective: To identify an age threshold associated with adjuvant chemotherapy drop-out, and to descriptively compare baseline characteristics, perioperative outcomes, and survival between patients who underwent upfront surgery versus neoadjuvant chemotherapy (NAC) above this threshold, acknowledging that treatment allocation was not randomized and reflected pre-existing clinical selection.
Methodology: A prospectively maintained database of 294 gastric cancer patients operated between September 2017 and December 2025 was retrospectively analyzed. ROC curve analysis and the Youden Index were used, within this same cohort, to identify an age cut-off associated with adjuvant therapy drop-out; this threshold should be considered hypothesis-generating rather than externally validated. Patients >=72 years (N=130) were stratified into Upfront Surgery (N=79) and NAC (N=51) cohorts based on the treating team’s actual clinical decisions. Postoperative morbidity was assessed using the Clavien-Dindo classification; survival was compared using Kaplan-Meier and Log-rank methods.
Results: The two cohorts differed substantially at baseline, reflecting deliberate clinical selection rather than comparable populations. Patients selected for upfront surgery were more frequently frail (ASA III-IV: 62.0% vs 29.4%, p=0.001) but had less advanced, more distally located disease. Patients selected for NAC had better baseline performance status but more advanced nodal involvement (cN+: 64.7% vs 34.6%, p=0.003) and more proximal or extensive tumors (p=0.004), which in turn required total gastrectomy more frequently (53% vs 33%, p=0.032) and longer operative times (436 vs 347 min, p<0.001). R0 resection rates were 86.3% (NAC) and 96.2% (Upfront, p=0.050). Overall medical-grade complications (CD ≥2) were more frequent in the Upfront cohort (62.0% vs 43.1%, p=0.047), consistent with its higher baseline frailty, while severe surgical complications (CD ≥3) did not differ significantly (8.9% vs 3.9%, p=0.481). No statistically significant differences were observed between cohorts in Overall Survival (Log-rank p=0.731) or Disease-Free Survival (Log-rank p=0.188).
Conclusions: n this retrospective, non-randomized comparison, elderly patients (>=72 years) selected for upfront surgery, despite being frailer, achieved oncological outcomes comparable to fitter patients selected for NAC who had more advanced disease and underwent more extensive resections. These findings suggest that experienced clinical selection can successfully match treatment intensity to patient fitness and tumor burden, achieving similar outcomes across markedly different-risk populations. They do not support broad conclusions about the relative efficacy of NAC versus upfront surgery in a given elderly patient, since the two strategies were applied to systematically different populations. Individualized decision-making based on frailty assessment and tumor characteristics, as practiced in this cohort, appears to yield acceptable outcomes.
Keywords: Elderly Patiens, Upfront Surgery, Neoadjuvant Treatment
49. MASTER-D2: Developing a Quality Assessment Tool for Gastrectomy with D2 Lymphadenectomy
Authors: Riadh Salem(1), Maria Bencivenga(2), Federica Filippini(2), Fabrizio Tedone(2), Sheraz Markar(1)
Affiliation: (1)University of Oxford, (2) University of Verona
Introduction: The operative steps and anatomical boundaries of standard gastrectomy with D2 lymphadenectomy are well established. The current unmet need is an agreed, video-verifiable standard defining how the operative field should appear following an appropriately performed procedure. Without this standard, surgical videos cannot be used reliably or consistently to assess operative quality.MASTER-D2 (Measuring And Standardising TEchnique in Robotic D2 Gastrectomy), a video-based surgical quality assessment tool, was developed to address this gap by translating accepted surgical principles into observable assessment criteria.
Objective: MASTER-D2 is being evaluated through a staged validation programme addressing content and construct evidence, reliability, and relationships with clinical outcomes. This abstract presents the Delphi-derived content, the resulting assessment tool and early findings from a mixed-methods pilot used to refine the instrument before formal validation.
Methodology: Content evidence was established through a three-round modified Delphi involving 15 expert surgeons from nine countries. Candidate items were generated by hierarchical task analysis of robotic standard distal and total gastrectomy with D2 lymphadenectomy, rated during two anonymous online rounds and finalised at an in-person meeting. Consensus was predefined as at least 80% agreement. The resulting tool assesses seven distal and eight total gastrectomy phases on a four-point scale across Exposure, Execution, Adverse Events and End-Product Quality. Five expert robotic gastric cancer surgeons were recruited to assess six full-length, unedited operations. Exploratory inter-rater reliability was estimated using intraclass correlation coefficients (ICC(2,1)).The pilot also examined how raters understood and applied the tool. A post-assessment online questionnaire contained eight five-point Likert items addressing structure, clarity, confidence and domain anchors. Semi-structured interviews explored scoring decisions, uncertainty and suggested improvements; recordings were transcribed and analysed thematically. Questionnaire, interview and ICC findings were integrated to identify recurrent response-process and usability problems.
Results: Consensus was reached on 86 statements, 62 of 67 for distal and 57 of 65 for total gastrectomy. Most importantly, consensus was reached on all 15 definitions of the anatomical boundaries and expected intraoperative appearance of a completed D2 lymphadenectomy. Internal consistency for these criteria was excellent (Cronbach’s alpha 0.93 in Round 2 and 0.92 in Round 3).Questionnaire responses from the pilot were positive overall. Respondents agreed that the structure was logical, the tool captured the critical aspects of the operation and the four domain anchors were clear. All reported a reduction in overall assessment time to around 90 minutes by the final video. Exploratory agreement was strongest during suprapancreatic dissection for Execution (ICC 0.739) and End-Product Quality (ICC 0.714), each across five assessable videos.The interviews explained where refinement was needed. Raters described a ceiling effect, score 4 represented near-perfect performance and was rarely used, so ratings clustered at 3. They also described a halo effect, in which an early overall impression of the surgeon influenced ratings across later phases. Percentage- and time-based anchors (e.g. target anatomy is visible < 25 % ) were difficult to judge by eye, Phase 1 (access and exposure) was often outside the console recording, and the tool was considered clinically detailed but lengthy.
Conclusions: MASTER-D2 does not propose a new method of gastrectomy or D2 lymphadenectomy. Its contribution is to make the accepted standard explicit and assessable from operative video, particularly by defining how a sound oncological dissection should look intraoperatively. The pilot found that experts considered the tool clinically logical and comprehensive, while identifying specific response-process problems that could be corrected before formal validation. Version 2.0 will now undergo a multicentre evaluation of reliability and construct evidence. Subsequent work will examine whether MASTER-D2 scores are associated with patient outcomes and whether the instrument can provide ground truth for future automated video assessment.
Keywords: Surgical Quality Assurance, D2 Lymphadenectomy, Video-Based Technical Assessment, Surgical Training
50. Robotic Surgery for Gastric GISTs: A Single-Center Experience in Complex Cases
Authors: Campi, Ludovico¹Lammes, Femke²Zeyara, Adam³,Badaloni, Franco²van den Berg, Jan Willem²Ruurda, Jelle²van Hillegersberg, Richard²
Affiliation: ¹Surgical Science Department, University of Turin, Turin 10126, Italy.²Department of Surgery, University Medical Center Utrecht, Utrecht 3584 CX, The Netherlands.³ Department of Surgery, Skåne University Hospital, Lund 221 85, Sweden.
Introduction: Minimally invasive approaches for gastric gastrointestinal stromal tumors (GISTs) are often limited by significant technical challenges, particularly regarding tumor mobilization and anatomical reconstruction. Although organ-preserving surgery remains the gold standard, achieving it can be highly demanding in cases involving large tumor diameters or unfavorable anatomical locations. In this context, robotic surgery emerges as a technological advancement that may overcome these traditional laparoscopic limitations, potentially improving safety and expanding the indications for minimally invasive treatment in complex scenarios.
Objective: The aim of this study is to evaluate safety and feasibility of robotic assisted minimally invasive approach for technically demanding gastric GISTs with a specific focus on large tumors and challenging anatomical locations.
Methodology: This retrospective, single-center study included 25 consecutive patients with gastric GISTs who underwent elective robot-assisted surgery using the da Vinci Xi system at the University Medical Center Utrecht between January 2020 and August 2025. Preoperative diagnosis was established via endoscopy and (PET)-CT scans, and tumor locations were categorized using the Privette/Al-Thani classification. Procedures were stratified by technical difficulty: lesions ≥ 50 mm and/or located in Privette type 2, 3, or 4 areas were classified as „difficult” (n = 21), while a subgroup presenting both features was defined as „ultra-difficult” (n = 10). The primary endpoints were intraoperative and oncological safety (defined by R0 resection rates and complications), while secondary endpoints included conversion rate, organ preservation, operative time, hospital stay, and postoperative morbidity. Descriptive statistics were used to analyze the outcomes.
Results: Between January 2020 and August 2025, a total of 25 consecutive patients were included during the study period. Most 21 (84%) tumors were classified as cT2 or higher; all patients were N0 and M0. According to Privette/Al-Thani classification, most tumours were type 3 (n = 17, 68.0%), followed by type 1 (n = 4, 16.0%), type 2 (n = 3, 12.0%), and type 4 (n = 1, 4.0%). Most tumors exhibited an exophytic pattern (22/25), two were endophytic, and one was a post-ESD recurrence. The median tumor size was 50 mm (range 3–170). Three patients received preoperative Imatinib. Procedures were stratified into difficulty categories based on tumor size and anatomical location: lesions ≥50 mm and/or in Privette type 2–3–4 areas were considered difficult (n=21). Among them, 10 were classified as “ultra-difficult”, having both large diameter and complex location. In this subgroup, the median tumor size was 80.3 mm (range 50–170), with eight tumors located in Privette type 3 areas. All wedge resections were completed by robotic minimally invasive surgery using hand-sewn closure, except for one distal gastrectomy, which required conversion for the largest tumor (170 mm). The only intraoperative tumor rupture occurred during mobilization of a 60 mm endophytic tumor in the lesser curvature/EGJ, which was the sole R1 resection. All other resections achieved R0, and no anastomotic leaks were detected. Median operative time was 82 minutes (range 41–186). Median hospital stay was 3 days (1–7). No postoperative Clavien–Dindo grade IIIb or higher complications were recorded. No gastrointestinal sequelae or subsequent endoscopic interventions were observed.
Conclusions: Our experience demonstrates that the robotic approach allows for the safe management of gastric GISTs, even in cases with difficult tumor locations, large size, or both. By successfully facilitating organ-sparing resections with excellent functional outcomes, robotic surgery represents the natural evolution of minimally invasive approaches, offering superior safety, precision, and functional preservation in complex gastric GIST management.
Keywords: Gastric gastrointestinal stromal tumors (GIST); Robotic surgery; Organ-sparing surgery.
51. Comparison between Comprehensive Complication Index (CCI) and Clavien-Dindo classification for assessing the complications burden after Gastrectomy for Gastric cancer in the GASTRODATA registry
Authors: Tedone F 1, Bencivenga M 1, Torroni L 2, Filippini F 1, Verlato G2, Hoelscher AH3, D’Ugo D4, Piessen G5, Wijnhoven B6, Schneider P7, Pera M8, Fumagalli U9, Polkowski W10, Van Sandick J11, Lara Santos L12, Allum WH13, Rosati R14, Reim D15, Moenig S16, Gockel I17, Baiocchi G18, Matos Da Costa P19, Kielan W20, van Berge Henegouwen MI21, de Manzoni G1, Morgagni P22, Gisbertz SS21,23, on behalf of the GASTRODATA group
Affiliation: 1.Unit of General and Upper GI Surgery, University of Verona, Verona, Italy
Introduction: Large population-based studies evaluating the burden of postoperative complications after gastrectomy for gastric cancer (GC) in Europe are lacking. Postoperative morbidity is commonly assessed using the Clavien-Dindo Classification (CDC), which records only the most severe complication per patient, or the Comprehensive Complication Index (CCI), which integrates all complications into a single score.
Objective: This study compared CDC and CCI in assessing postoperative outcomes after open (OG) and minimally invasive gastrectomy (MIG) in a large European cohort.
Methodology: This retrospective study included patients undergoing curative-intent gastrectomy for GC between January 2017 and December 2021 at 24 European centers participating in the prospective GASTRODATA registry. Primary outcomes were the associations of CDC and CCI with postoperative recovery, including hospital stay, reoperation, 30- and 90-day mortality, and postoperative chemotherapy within 90 days. Secondary outcomes included the correspondence between CDC and CCI in patients with complications. Statistical analyses used chi-square/Fisher’s exact tests, Mann–Whitney U tests, and Spearman correlation coefficients with Rho-to-Z transformation.
Results: Among 2430 included patients, 686 (28.2%) had at least one postoperative complication. In total, 66 patients (9.6%) with multiple complications of lower CDC grade had corresponding CCI values equal to higher CDC grading (Fig. 1). This cross-over occurred most often in CDC IIIa (29/66, 44%). The CCI correlated significantly better when compared to CDC with length of hospital stay (rs=.466 vs s=.0.397, p=0.013). No other significant correlations were observed for either classification system.
Conclusions: In this large European cohort, the CCI better captured the overall burden of postoperative morbidity after gastrectomy for GC, particularly in relation to hospital stay. However, both CCI and CDC showed similar associations with reoperation and mortality, outcomes likely driven by the most severe complication. The CCI may therefore provide complementary information for evaluating the quality of the entire oncological care pathway.
Keywords: Gastric Cancer, Postoperative complications, Clavien-Dindo Classification, Comprehensive Complication Index, GASTRODATA
52. Gastric Cancer in Young Adults and on older individuals: Comparison of pathological and clinical characteristics
Authors: Fabrizio Tedone1, Lorena Torroni2,3, Jane Kim4, Maria Bencivenga1, Federica Filippini1, Paulo Kassab5, Osvaldo Antonio Prado Castro5, Etsuro Bando6, Masanori Terashima6, Alberto Takahashi7, Enver Ilhan8, Ali Alemdar9, Suzanne Sarah Gisbertz10,11, Manuel Pera11, Enrique Biel11, Mariagiulia Dal Cero11, Han-Kwan Yang3, Giovanni de Manzoni4, Giuseppe Verlato1 and Hyuk-Joon Lee3
Affiliation: 1. Unit of General and Upper GI Surgery, University of Verona, Verona, Italy
Introduction: Gastric cancer remains a major contributor to global cancer morbidity and mortality, despite a steady decline in overall incidence worldwide. However, this decline has not been uniform across age groups and areas. Indeed, recent epidemiologic data suggest a concerning increase in the proportion of early-onset gastric cancer, commonly defined as gastric cancer diagnosed before the age of 45-50 years, indicating a shift in disease burden toward younger populations.
Objective: This study compares Gastric Cancer in Young Adults (GCYA) prevalence by country, histology, and survival to Gastric Cancer in Adults (GCA).
Methodology: We performed a retrospective, multicentric, international study of 7,320 patients who underwent GC surgery (2010–2020) across nine centers (Verona, Amsterdam, Barcelona, Izmir, Istanbul, New Mexico, São Paulo, Shizuoka, Seoul). Of these, 6,602 were GCA cases, and 718 were GCYA cases.
Results: Most GCA patients were male (65.4%), while 52.9% were female in GCYA. The median ages were 65 years (IQR=57-73) for GCA and 40 years (37-43) for GCYA. The distribution of the collected diagnoses of GC shows a bimodal trend: the main peak occurs around 65 years old, and the second and minor one occurs around 40. In the GCYA, the clinical stage of the tumour and the TNM at pathological examination were lower in Asian countries than elsewhere. Histological classifications for GCA and GCYA patients varied between centers. Among GCA patients, intestinal and diffuse histology were prevalent in the West, whereas mixed histology was more common in the East. In Western centers, GCYA cases were primarily intestinal (19%) or diffuse (70%), while in Eastern centers, diffuse histology predominated (73%). The Overall survival (OS) in the GCYA group did not differ between the Western centres; in contrast, OS was significantly higher in the Eastern, with a five-year survival of 88.2% (CI 95%: 0.85-0.91) (p<0.001).
Conclusions: Over the past ten years, new diagnoses peaked at ages less than 50. This new trend can be found in countries with different ethnicities and risk factors for Gastric Cancer development. Screening programs focused on young people should be planned.
Keywords: Gastric Cancer, Young patients, Epidemiology, International study, Retrospective analysis
53. Refining Surgical Strategy in Elderly Patients: Subtotal vs Total Gastrectomy for Poorly Cohesive Gastric Cancer
Authors: De Martino Renato MD 1,2, Giorgi Lorenzo MD 3, Casiraghi Marta MD 1,2, Pansa Andrea MD 3, Alfieri Rita MD 3, Garbarino Giovanni Maria MD PhD 1,3, Basato Silvia MD 3, Castoro Carlo MD 1,3
Affiliation: 1. Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy 2. IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy 3. Upper Gastrointestinal Surgery Unit, IRCCS Humanitas Research Hospital, 20089 Milan, Italy.
Introduction: The surgical management of poorly cohesive/signet ring cell (SRC) gastric cancer traditionally favors total gastrectomy (TG) due to the tumor’s aggressive intramural spread. However, considering the high morbidity of TG in elderly patients, the potential oncological detriment of a subtotal gastrectomy (SG) remains a subject of debate.
Objective: This retrospective study aimed to explore whether SG represents a safe and feasible oncological alternative to TG in selected elderly patients with SRC gastric cancer.
Methodology: A retrospective analysis was conducted on elderly patients (>70 years) who underwent gastrectomy for gastric cancer from September 2017 to December 2024 at Humanitas Research Hospital, with a minimum follow-up of 1 year. The analysis specifically focused on patients with poorly cohesive carcinoma (PCC) with or without SRC. Categorical variables were analyzed using Fisher’s exact test. Survival outcomes, including Overall Survival (OS) and Disease-Free Survival (DFS), were evaluated using the Kaplan-Meier method and compared via the log-rank test.
Results: Out of 88 elderly patients operated on during the study period, 42 presented with PCC/SRC histology (22 TG, 20 SG). The TG and SG cohorts were well-balanced regarding the primary prognostic factors, including advanced pT stage (T3-T4: 68.2% vs. 65.0%, respectively; p=1.000) and nodal involvement (N+ vs N0; p=0.741). Despite the parenchymal-sparing approach, SG did not show a statistically significant difference in R0 resection rates compared to TG (85.0% vs. 81.8%, respectively; p=1.000), with all R1 positive margins in the SG group being localized distally. Furthermore, survival analysis revealed no significant detriment in long-term outcomes for the SG group, with comparable recurrence rates (50.0% SG vs. 45.5% TG; p=1.000) and no significant differences in DFS (log-rank p=0.804) or OS (log-rank p=0.624). Major postoperative complications were infrequent and did not differ materially between groups.
Conclusions: In this small retrospective series of elderly patients with poorly cohesive gastric cancer, subtotal gastrectomy showed comparable observed R0 resection rates and survival outcomes to total gastrectomy in this cohort. These findings are preliminary and suggest that a conservative approach may deserve further consideration in technically suitable cases.
Keywords: Elderly Patients, Subtotal Gastrectomy, Poorly Cohesive Gastric Cancer
54. Treatment delivery, dose intensity and outcomes across peritoneal metastatic phenotypes in advanced gastric and gastro-oesophageal junction adenocarcinoma: a Swedish real-world cohort
Authors: Elina Azizi1, Osama Hamida2,3, Linn Werth3, Ida Lagstam4 Magnus Nilsson1,5, Lisa Liu Burström1,2,5
Affiliation: 1. Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden 2. Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden 3. Theme Cancer, Karolinska University Hospital, Stockholm, Sweden 4. Department of Oncology, Faculty of Medicine and Health Örebro University, Örebro, Sweden 5. Department of Upper Abdominal Diseases, Theme Cancer, K
Introduction: Peritoneal metastases (PM) are common in gastric (GC) and gastro-oesophageal junction (GEJ) adenocarcinoma. Whether PM confers worse outcomes, and whether the regimens PM patients receive reflect biology or under-treatment, remains unclear.
Objective: We examined treatment delivery, dose intensity, and survival by metastatic phenotype.
Methodology: We retrospectively analysed 345 patients with metastatic GC/GEJ adenocarcinoma planned for palliative systemic therapy (2019 to 2025) at Karolinska University Hospital. Patients were classified as isolated PM, mixed (PM and other metastatic sites), or non-PM (other metastatic sites only). Endpoints were first-line regimen, average relative dose intensity (ARDI, actual-time method), overall and progression-free survival (OS/PFS), and site of first progression (competing-risks methods). Cox and Fine-Gray models were adjusted for ECOG, age, and sex.
Results: Among 338 phenotyped patients (isolated PM 98, mixed 98, non-PM 142), chemotherapy-only first-line treatment was most frequent in isolated PM (93.5% vs 85.1% vs 73.1%) and any targeted therapy (anti-HER2/Immune check point inhibitors) least frequent (6.5% vs 14.9% vs 26.9%; p=0.001). This paralleled lower HER2 positivity (5.1% vs 9.2% vs 18%) and lower PD-L1 CPS≥1 among tested patients (38.0% vs 42.9% vs 59.3%). Dose intensity was reduced across all phenotypes (median ARDI isolated PM 74%, mixed 65%, non-PM 69%); the unadjusted difference (lowest in mixed, p=0.034) did not persist after adjustment, indicating no PM-specific under-dosing. OS and PFS were similar across phenotypes (adjusted OS HR 1.22, 95% CI 0.92 to 1.61 for isolated PM; 1.05, 0.78 to 1.41 for mixed; PFS HR 1.13 and 1.06); ECOG≥2 was the dominant prognostic factor (OS HR 2.0). As expected but not previously quantified, first progression was strongly phenotype-dependent: PM patients progressed preferentially in the peritoneum and non-PM patients predominantly at other sites (Fine-Gray sHR for peritoneal progression 16.5, 95% CI 5.98 to 45.6 isolated PM; 4.88, 1.63 to 14.6 mixed; p=<0.01).
Conclusions: PM phenotypes showed no evidence of reduced dose intensity or worse survival. Regimen and biomarker differences are consistent with biology-driven rather than phenotype-driven treatment selection. Competing-risks analysis confirmed and quantified a strong peritoneal pattern of first progression. To our knowledge, this is the first study to stratify systemic dose intensity by metastatic site in gastric/GEJ cancer.
Keywords: Gastric Cancer, Gastro-oesophageal junction cancer, Peritoneal Metastases
55. Early and Severe Gastrointestinal Toxicity with Zolbetuximab: A FAERS Signal Analysis in GI Cancers
Authors: Ekram Hassan Hasani
Affiliation: Faculty of Medicine, University of Tripoli, Tripoli, Libya
Introduction: Zolbetuximab, a Claudin 18.2–targeting monoclonal antibody, has emerged as a novel therapeutic option in gastrointestinal cancers. However, its use is associated with a distinct gastrointestinal toxicity profile. particularly severe nausea and vomiting, likely related to on-target effects on gastric mucosa.
Objective: While clinical trials have characterized these events, real-world pharmacovigilance data from FAERS may better define their frequency and clinical impact, supporting optimized toxicity management strategies.
Methodology: FAERS reports from 2019 to 2026 were queried to identify cases involving zolbetuximab in gastrointestinal cancers. Adverse events of interest, including nausea, vomiting, and related gastrointestinal toxicities, were identified using MedDRA preferred terms. Cases were evaluated for frequency, seriousness, and clinical outcomes, including hospitalization and death. Descriptive analyses were performed to characterize safetysignals.
Results: A total of 551 FAERS reports associated with zolbetuximab in gastrointestinal cancers were identified, of which 518 (94.0%) were classified as serious. The most frequently reported adverse events were nausea (229 cases, 41.6%) and vomiting (94 cases, 17.1%), representing the predominant toxicity profile. Overall, gastrointestinal toxicities were reported in approximately 46% of cases. Regarding outcomes, hospitalization was reported in 209 cases (37.9%), while no deaths were observed.The pattern of adverse events suggests a clustering of gastrointestinal symptoms, likely occurring early during treatment.
Conclusions: FAERS data demonstrate a strong and clinically significant signal of gastrointestinal toxicity with zolbetuximab, characterized by high rates of nausea, vomiting, and hospitalization, but no associated mortality. These findings support a predictable, on-target toxicity profile and highlight the need for proactive and optimized supportive care strategies.
Keywords: zolbetuximab , gastrointestinal cancers , pharmacovigilance
56. Real-World FAERS Analysis Identifies a High-Risk Signal of Interstitial Lung Disease with TrastuzumabDeruxtecan in Gastrointestinal Cancers
Authors: Ekram Hassan Hasanin
Affiliation: Faculty of Medicine, University of Tripoli, Tripoli, Libya
Introduction: Trastuzumab deruxtecan, an antibody–drug conjugate targeting HER2, has demonstrated significant efficacy in gastrointestinal cancers. However, interstitial lung disease (ILD)/pneumonitis has emerged as a key safety concern.
Objective: Real-world pharmacovigilance data from FAERS may better characterize the incidence and severity of this toxicity beyond clinical trials.
Methodology: FAERS reports from 2019 to 2026 were queried to identify cases involving trastuzumab deruxtecan in gastrointestinal cancers. Adverse events of interest, particularly interstitial lung disease (ILD)/pneumonitis, were identified using MedDRA preferred terms. Cases were evaluated for frequency, seriousness, and outcomes, including death and hospitalization. Descriptive analyses were performed to characterize safety signals.
Results: A total of 41 FAERS reports associated with trastuzumab deruxtecan in gastrointestinal malignancies were identified. Most cases were serious (38/41, 92.7%), reflecting a high burden of clinically significant adverse events. was the most frequently reported toxicity, occurring in 33 casesInterstitial lung disease (ILD)/pneumonitis (80.5%), representing the predominant safety signal. Other reported adverse events were infrequent and notconsistently observed.Regarding outcomes, death was reported in 10 cases (24.4%), indicating a substantial fatality proportion among reported events. Hospitalization and other serious outcomes were also commonly documented, often in association with pulmonary toxicity.Overall, FAERS data demonstrates a strong and clinically meaningful signal for ILD associated with trastuzumab deruxtecan, characterized by high seriousness and notable mortality.
Conclusions: FAERS data reveal a pronounced and clinically critical signal of ILD/pneumonitis with trastuzumab deruxtecan in GI cancers, marked by high severity and mortality, establishing ILD as the key limiting toxicity and emphasizing the urgent need for vigilant monitoring and immediate intervention.
Keywords: trastuzumab deruxtecan , GI cancers , pharmacovigilance
57. Claudin18.2 Expression Dynamics After Neoadjuvant Therapy in Locally Advanced Gastric Cancer
Authors: Hongming Liu, Bixian Luo, Weihua Gong
Affiliation: Department of Surgery, Second Affiliated Hospital of School of Medicine, Zhejiang University, Hangzhou, 310058, China.
Introduction: CLDN18.2 is an emerging therapeutic target in gastric cancer, but its expression may change during neoadjuvant treatment, and the clinical significance of this change remains unclear.
Objective: This study investigated the change of CLDN18.2 expression during NAT in patients with locally advanced gastric cancer and its correlation with clinicopathologic features.
Methodology: A retrospective study was conducted, including 198 patients with locally advanced gastric cancer who received NAT followed by gastrectomy between 2020 and 2024 at two medical centers in China. CLDN18.2 (43-14A) was assessed by immunohistochemistry in paired specimens, with positivity defined as moderate-to-strong membranous staining in ≥75% of tumor cells.
Results: Among 198 patients, 70 (35.4%) were CLDN18.2-positive at baseline; 163 patients with residual disease had paired specimens. CLDN18.2 positivity was 39.3% before and 43.6% after NAT, with 69.9% concordance (κ=0.382). Negative-to-positive and positive-to-negative conversions occurred in 17.2% and 12.9% of patients, respectively. More than three NAT cycles independently predicted negative-to-positive conversion (OR 5.50, 95% CI 1.25–24.21; P=0.024). Pretreatment CLDN18.2 status and conversion patterns were not significantly associated with major pathological response or overall survival.
Conclusions: CLDN18.2 exhibits favorable concordance after NAT in gastric cancer, but status still changed in some tumors. Post-neoadjuvant CLDN18.2 reassessment should be considered. Longer NAT duration was associated with acquisition of CLDN18.2 positivity.
Keywords: Gastric cancer; Claudin18.2; Neoadjuvant therapy; Dynamics
58. Multivisceral Resections for the Treatment of Locally Advanced Gastric Cancer
Authors: Alicja Boniukiewicz, Renata Kucala-Kozakowska, Przemysław Rajca, Piotr Richter
Affiliation: First Department of Surgery, Jagiellonian University Medical College, Kraków, Poland
Introduction: Despite improvements in systemic therapy regimens, oncologic resection with negative specimen margins and adequate lymphadenectomy remains the mainstay of gastric cancer treatment. As most cases of gastric cancer in the West are diagnosed at a late stage, locally advanced gastric cancer involving adjacent tissues may require en bloc multivisceral resection (MVR) to allow for surgical radicality. Patients with radiologic and intraoperative findings suggestive of T4b disease are potential candidates for multivisceral resection; however, true neoplastic infiltration of adjacent tissues may not be readily distinguished from desmoplastic inflammatory responses, posing a surgical dilemma.
Objective: The aim of this study was to evaluate the perioperative and oncological outcomes of multiorgan resections performed for locally advanced gastric cancer in an academic surgical centre.
Methodology: A retrospective analysis was performed on patients with locally advanced gastric cancer subject to stomach resection combined with the removal of adjacent organs considered affected by direct infiltration at the time of surgery, at the First Department of Surgery, Jagiellonian University Medical College, between May 2023 and May 2026. Demographic data, tumour location, macroscopic and histopathological findings, TNM classification, type of surgical strategy, extent of lymphadenectomy, perioperative complications and mortality were analysed.
Results: In the 3-year period reported, among 74 complete or partial stomach resections performed for gastric cancer, 14 cases constituted multivisceral resections. Median patient age was 66.5. The male-to-female ratio was 8:6. All MVRs conducted involved total gastrectomy. The most prevalent adjacent organs associated were the spleen (10), pancreas (4), transverse colon or its mesentery (2), left liver lobe (1), and diaphragm (1). In the pancreas group, surgical intervention was extended to distal pancreatectomy (2), pancreatoduodenectomy (1), and partial removal of the pancreatic head. A radical (R0) resection was achieved in 10 patients who underwent MVR. Gastrectomy combined with the removal of one perigastric organ was performed in 9 patients, while gastrectomy along with the resection of two organs was conducted in 5 patients. Pathological T4 disease was confirmed in 5 cases, with pT4a in 4 and pT4b in 1. The overall complication rate was 100%, and severe complications (i.e., grade 3a or higher on the Clavien-Dindo scale) were reported in 2 cases. The most frequently reported complications were anaemia requiring blood transfusion, surgical site infection, pancreatic fistula, and intra-abdominal abscess. Perioperative mortality was found to be 0%, while perioperative mortality in patients who underwent gastrectomy alone was 4/60 (7%). Thus, MVRs were associated with higher proportions of surgical and general complications, but not mortality, when compared with gastrectomy alone.
Conclusions: Gastrectomy, along with multiorgan resection, may be a feasible treatment option in patients with locally advanced gastric cancer, allowing for radical resection margins and thus ensuring favourable oncological outcomes. Whereas the complication rate, both general and surgical, remains significant, perioperative mortality reported in this study was not higher than that of gastrectomy alone.
Keywords: locally advanced gastric cancer, multivisceral resection, multiorgan resection
59. Epigenetic Mechanisms Bridging Research and Clinical Evaluation in hMLH1-Hypermethylated Gastric Cancer (EMBRACE-hGC): A Retrospective Cohort Study of Mismatch Repair Deficiency and Clinical Implications
Authors: Annamaria Agnes, Laura Lorenzon, Francesco Belia, Francesca Chicchi, Pasquale Moretta, Lorenzo Rocca, Massimo Pascariello, Maria De Bonis, Natalia Cappoli, Riccardo Ricci, Maria Cristina Giustiniani, Antonia Strippoli, Carmelo Pozzo, Alessia Piermattei, Angelo Minucci, Giampaolo Tortora, Domenico D’Ugo, Alberto Biondi, Roberto Persiani
Affiliation: Fondazione Policlinico Universitario A. Gemelli IRCCS
Introduction: Gastric cancer is a molecularly heterogeneous disease, and immunohistochemistry-detected mismatch-repair deficiency (dMMR) does not represent a single biological entity.
Objective: We evaluated the concordance between dMMR and microsatellite instability (MSI), and assessed whether hMLH1 promoter hypermethylation identifies a distinct sporadic dMMR subgroup with specific clinicopathological and therapeutic features.
Methodology: We conducted a retrospective single-center study including consecutive patients with gastric adenocarcinoma evaluated for surgery between 2017 and 2024. Cases with available MMR immunohistochemistry were further analyzed for MSI status, hMLH1 promoter methylation, and BRAF V600E mutation on formalin-fixed paraffin-embedded tissue. Clinicopathological characteristics, response to neoadjuvant therapy, and survival were examined.
Results: Among 314 patients with available MMR immunohistochemistry, 67 (21.3%) had dMMR tumors. Molecular profiling was feasible in 52 cases, of which 41 (78.8%) showed hMLH1 promoter hypermethylation. The methylated group was associated with older age and distal tumor location. All hMLH1-methylated tumors exhibited MSI, with the vast majority classified as MSI-high, whereas concordance with MSI was lower among non-methylated dMMR tumors. No BRAF V600E mutations were detected. Median PD-L1 CPS values were higher in the dMMR, MSI-H, and hMLH1-methylated groups compared to the pMMR group. Exploratory analyses suggested a limited pathological response to neoadjuvant therapy. No significant differences in overall survival were detected in the dMMR, MSI-H, and hMLH1-methylated groups vs the pMMR group. The dMMR group had the highest overall survival (median > 60 months).
Conclusions: hMLH1 promoter hypermethylation defines a prevalent and biologically distinct subset of dMMR gastric cancer with characteristic clinicopathological features and potential therapeutic relevance. Our findings support moving beyond dMMR alone toward integrated biomarker stratification to better inform future research and treatment selection.
Keywords: Gastric cancer, hMLH1 hypermethylation, MSI-H, epigenetics, neoadjuvant chemotherapy
60. Reconstruction with Lawrence-Hunt Jejunal Pouch After Totally Mini-Invasive Gastrectomy
Authors: Annamaria Agnes, Laura Lorenzon, Lorenzo Rocca, Pasquale Moretta, Francesca Chicchi, Massimo Pascariello, Lorenzo Ferri, Flavio Tirelli, Domenico D’Ugo, Roberto Persiani, Alberto Biondi
Affiliation: Fondazione Policlinico Universitario A. Gemelli IRCSS
Introduction: Total gastrectomy is performed for various gastric malignancies. Postoperative complications include weight loss, nutritional deficiencies, and functional issues like reflux and dumping syndrome, affecting quality of life. Jejunal pouch reconstruction may help mitigate this condition by slowing gastric emptying and enhancing nutrient absorption.
Objective: With the REJOY phase II trial – NCT NCT06967571 – we aim to establish the efficacy of jejunal pouch reconstruction in reducing dumping syndrome in patients undergoing total gastrectomy, ultimately enhancing postoperative quality of life and nutritional status.
Methodology: The REJOY study is currently recruiting. With this video, we present the reconstruction technique as performed during laparoscopic and robotic total gastrectomy. Technical challenges will be discussed.
Keywords: gastric cancer, total gastrectomy, jejunal pouch
61. Snus use and gastric cancer incidence: a nationwide cohort study of 4.5 million adults in the Swedish Tobacco Cohort (SWETOC).
Authors: Jonathan Engborg, Magnus Olsson, Hanne Tønnesen, Aron Naimi-Akbar, Johan Sundström, Jakob Hedberg
Affiliation: Uppsala University, Uppsala, Sweden
Introduction: Snus (an oral smokeless tobacco) is a primarily Swedish way of consuming Tobacco delivering delivering possibly carcinogenic compounds, such as nitrosamines, to the upper gastrointestinal tract. Combined with the advent of the nicotine pouch (tobacco-free snus) which is expected to greatly increase snus use not only in Scandinavia. Evidence to date is sparse and often confounded by concurrent smoking.
Objective: To investigate the possible association between snus use and incidence of gastric cancer (ICD-10, C16), independent of smoking.
Methodology: We collected data on snus use and smoking in 4,476,495 adults in the Swedish dental care register from the first digitized dental visit until a diagnosis of cancer, death or end-of-followup (31st December, 2022). Snus use and smoking was then classified as never, mixed and always (consistent) use. Gastric cancer incidence was identified from the Swedish Cancer Register where persons with prior cancer were excluded. Cox proportional hazards models estimated hazard ratios (HR) with 95% confidence intervals, adjusted for age, sex, education, birth region, and separately for smoking and snus use. Sensitivity analyses were performed and restricted to never-smokers.
Results: In a total of 49.8 million person-years (median follow-up of 11.1 years), 3,619 gastric cancers occured. Snus use was not associated with gastric cancer (Always vs. never snus HR 0.95, 0.81 -1.12). This result persisted among never-smokers (Always snus HR 0.99, 0.82-1.20), in joint-exposure analysis (HR 1.01, 0.84-1.22), as well as across all follow-up time strata. Smoking was clearly associated (always vs. never smokers HR 1.78, 1.58-2.00), validating the models detection of real effects. Individuals born outside of Sweden also had an elevated risk (HR 2.0), consistent with H. pylori prevalence.
Conclusions: We found no association between snus use and gastric cancer incidence, whereas smoking was a strong risk factor, arguing against a meaningful role for snus in gastric carcinogenesis.
Keywords: gastric cancer; snus; smokeless tobacco; smoking; cohort study; Sweden
62. Upfront Surgery versus NeoAdjuvant Chemotherapy. A retrospective study with matched treatment comparison.
Authors: Reddavid R, Torrioni L, Barbiero M, Degiuli M.
Affiliation: University of Turin
Introduction: Based on the concerns about the actual low strength of evidence of the efficacy of NAC on survival of proper gastric cancer treated with adequate D2 gastrectomy as compared to the results of optimal upfront surgery (S), and considering the actual difficulties of additional RCTs, the aim of this study is to assess the non-inferiority of upfront surgery alone with optimal D2 dissection compared to NAC regimens followed by surgery.
Objective: The aim of this study is to assess the non-inferiority of upfront surgery alone with optimal D2 dissection compared to NAC regimens followed by surgery in an observational retrospective multicenter Study with matched treatment comparison, including resectable advanced cancer of the stomach with the exclusion of cardia cancers.
Methodology: This is a nationwide Multicenter observational retrospective study with matched comparison of two therapeutic strategies (NAC vs S). We will include patients with cT>2, every cN M0, or with every T and N+ M0, histologically proven adenocarcinoma of the stomach, submitted either to pre- or peri-operative treatment and D2 gastrectomy or to upfront D2 gastrectomy, between January 2012 and December 2019, followed by adjuvant treatment when recommended.All patients matching the inclusion/exclusion criteria will be registered into the study and classified into one of the two arms: a, patients who underwent pre- or perioperative treatment and D2 gastrectomy (NAC) or b, patients submitted to upfront D2 gastrectomy (S). Given the results reported in the “FLOT” trial, a 3-years OS of 55% in the control arm (NAC) was assumed. Three-year OS in the experimental arm (S) was assumed to be 47.4% under the null hypothesis of inferiority and 55% under the alternative hypothesis of non-inferiority. A sample size of 684 patients (342 in each arm) achieves 80% power to detect a non-inferiority margin Hazard Ratio of 1.25.
Results: A total of 817 patients have been enrolled in 23 referral centers, 387 (47.37%) in arm a, and 430 (52.63%) in arm b. The overall survival analysis using a Cox proportional hazards model showed a hazard ratio of 0.67 (90% CI: 0.54–0.83) in favor of the experimental treatment (Surgery). Since the upper limit of the 90% CI (0.83) is below the predefined non-inferiority margin of 1.25, the experimental treatment meets the criterion for non-inferiority compared with the control. Furthermore, the HR < 1 indicates a 33% reduction in the risk of death compared with the control group, suggesting a clinically meaningful trend toward superiority. The disease free survival resulted comparable between the two group (p=0.299). After multiple imputation and inverse probability of treatment weighting (IPTW), surgery was associated with an absolute reduction in the risk of mortality of 10.3% compared with NAC (ATE = −0.103; 95% CI, −18.0% to −2.5%; p = 0.010). Given that the estimated risk of mortality in the NAC group was 35.2%, this difference corresponds to an approximate 29% relative risk reduction.
Conclusions: In locally advanced, resectable gastric adenocarcinoma, upfront surgery seems to improve overall survival compared with perioperative NAC.
Keywords: Gastric cancer, upfront surgery, neoadjuvant chemotherapy
63. Gastropancreatectomy for the Treatment of Locally Advanced Gastric Cancer
Authors: Renata Kucala-Kozakowska, Alicja Boniukiewicz, Piotr Richter
Affiliation: First Department of Surgery, Jagiellonian University Medical College, Kraków, Poland
Introduction: Locally advanced gastric cancer remains a significant therapeutic challenge despite advances in multimodal treatment strategies. Radical surgical resection with negative margins (R0 resection) is the basis of effective treatment. In selected patients, direct tumor invasion into adjacent organs, including the pancreas, necessitates extended multivisceral resection to achieve complete oncological clearance. Gastropancreatectomy is among the most technically demanding procedures in gastric cancer surgery and is associated with increased perioperative morbidity.
Objective: The aim of this study was to evaluate the perioperative and oncological outcomes of gastropancreatectomy performed for locally advanced gastric cancer, with particular emphasis on postoperative morbidity, pathological radicality (R0 resection rate), and overall survival.
Methodology: A retrospective analysis was performed on patients with locally advanced gastric cancer who underwent gastropancreatectomy at the First Department of Surgery, Jagiellonian University Medical College between 2019 and 2026. Demographic characteristics, clinicopathological data, perioperative outcomes, postoperative complications, pathological findings, and survival outcomes were analyzed.
Results: Three patients underwent gastropancreatectomy for locally advanced gastric cancer. The follow-up periods were 36, 31, and 62 months. Two patients received neoadjuvant therapy, were in good general condition at the time of surgery, achieved an R0 resection, and demonstrated favorable oncological outcomes during follow-up. The third patient, who did not receive neoadjuvant treatment due to significant comorbidities and had an unfavorable preoperative prognosis, experienced an unfavorable clinical outcome.
Conclusions: Gastropancreatectomy is an effective treatment option for a selected group of patients with locally advanced gastric cancer requiring multiorgan resection. The procedure is associated with significant perioperative risk; however, complete tumor resection can provide favorable oncological outcomes. Careful patient selection and treatment at experienced high-volume centers are essential to maximize the oncological benefits of this aggressive surgical approach.
Keywords: Locally advanced gastric cancer, Gastropancreatectomy, Multivisceral resection,Neoadjuvant therapy, R0 resection
64. Multicenter Italian validation of KOQUSS-40 questionnaire assessing QoL of gastric cancer patients after gastrectomy
Authors: F. Filippini (1), F. Tedone (1), L. Torroni (2), J Sang-Ho (3), G. Baiocchi (4), G.A. Tiberio (5), D. Zattoni (6), S. Vellei (7), G. Vittimberga (8), L. Solaini (9), D. Marrelli (10), F.Marchesi (11), M. Valente (11), R. Reddavid (12), M. Milone (13), G. Garulli (14), F. Steccanella (15), F. Zoccola (15), Hk. Yang (16), G. De Manzoni (1), M. Bencivenga (1) and Hj Lee (16).
Affiliation: 1 Department of general and upper GI surgery, University of Verona, Italy 2 Department of Public Health and Statistics, University of Verona, Italy 3 Department of Surgery, Gyeongsang National University Changwon Hospital, Changwon, Korea. 4 Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy. 5 Surgical Clinic, Department of Clinical and Experimental Sciences,
Introduction: KOQUSS-40 questionnaire, developed by KOrean QUality of life in Stomach cancer patients Study group, assesses post-gastrectomy symptoms, filling a gap left by existing tools, as EORTC QLQ-C30 and QLQ-STO22 questionnaires.
Objective: This study aims to validate KOQUSS-40 questionnaire in a large Western context.
Methodology: After translation, and back translation from English to Italian, KOQUSS-40 questionnaire was tested for a qualitative interview of 20 patients after gastrectomy, at Upper-GI Surgery of Verona, Italy. Due to the emerging differences, 3 items were modified and 1 was added, elaborating IQUSS-41. Firstly, IQUSS-41 was tested on 92 patients for comprehensibility and cultural adaptation. Criterion validity was assessed comparing IQUSS-41 scores with EORTC questionnaires. Items were rated on a 4-point Likert scale, analyzed using mean and standard deviation. Following „rule of ten”, a population of 400 patients will be enrolled. Random sample of 100 patients will be considered for test-retest reliability. Italian multicenter validation phase runs from January 2023 to December 2025.
Results: First item analysis on 92 patients showed that, after cultural adaptation, IQUSS-41 was suitable for Western patients. Missing answers were due to errors or low education levels so,few changes,including simpler vocabulary and an added sub-question, were made before the multicenter phase on 400 patients. Since January 2023,290 patients, from 12 Centers, have been enrolled. Median age was 70 years,62.8% male and 53.8% BMI>25.Most had pT≥3(51.6%),N0(57.9%)and M0(95.1%)gastric cancer.36.9% underwent total gastrectomy and D2-lymphadenectomy(73.3%), mainly with open technique(50.9%). Content analysis identified 6 domains, after factor analysis. This distribution differed from Korean results, likely due to Italian Health System and cultural adaptation. Clinical validity was assessed by comparing mean scores across domains for different groups, based on surgery extent(subtotal vs. total gastrectomy)and approach (open vs. minimally-invasive).Criterion validity showed good correlation between IQUSS-41 and EORTC questionnaires.
Conclusions: We demonstrated effective cultural adaptation of KOQUSS-40 questionnaire for Western population, elaborating IQUSS-41.The ongoing multicenter phase aims to validate the final version on 400 Italian patients, that could represent a useful tool for clinical trial.
Keywords: quality of life, gastric cancer, questionnaire, Korean KOQUSS-40
65. Randomized, prospective study of the impact of microjejunostomy after gastrectomy (PROMIGA study): impact on body weight change and adjuvant chemotherapy administration
Authors: Maciej Gaciong; Katarzyna Marcisz-Grzanka; Łukasz Zyskowski; Monika Bieniasz; Lucjan Wyrwicz; Krystyna Tkaczyk; Leszek Zając; Adam Dmitruk; Tomasz Olesiński
Affiliation: Maria Sklodowska-Curie National Institute of Oncology – National Research Institute, Warsaw, Poland
Introduction: Curative resection combined with perioperative chemotherapy remains the standard of care for resectable gastric cancer (GC) and gastroesophageal junction (GEJ) cancer. The vital component of this care-enhancing postoperative recovery is nutritional support.
Objective: To evaluate the role of elective prolonged enteral nutrition via microjejunostomy in the prevention of weight loss and improvement of tolerance of adjuvant chemotherapy.
Methodology: It was an academic, randomized, prospective study conducted at Maria Sklodowska-Curie National Research Institute of Oncology in Warsaw, Poland. Patients were qualified for standard-of-care perioperative systemic treatment. Patients were randomized into two groups. After hospital discharge, patients in the control group (CG) did not receive enteral nutritional support, while in the microjejunostomy group (MG), enteral nutrition was continued for three months after surgery with nutritional support up to 1000 kcal per day. The primary outcome was postsurgical weight loss assessed at 3 months. Secondary outcomes included tolerance of postoperative chemotherapy, toxicity (CTCAE 5.0), PFS, OS, and QoL.
Results: Between September 2018 and June 2025, a total of 164 patients (MG: n=88; CG: n=76), aged 25–88 years (median 67; 66.5% males, 33.5% females), were included. Patients receiving enteral nutrition experienced significantly less weight loss compared to controls (median −4.0 kg [IQR −6.5 to −2.5] vs −7.0 kg [IQR −10.0 to −4.0]; p=0.012). They also demonstrated a significantly smaller decrease in BMI (median −1.6 kg/m² [IQR −2.1 to −0.9] vs −2.4 kg/m² [IQR −3.3 to −1.6]; p=0.007). 70.1% (115) of patients completed four cycles of postoperative chemotherapy, with no difference in completion of 4 or 3 cycles between groups (p=0.224 and p=0.723, respectively). No difference was observed in the proportion of patients requiring dose reduction (MG: 58.1% vs CG: 62.0%; p=0.337). Statistically significant differences were observed in the proportion of patients with nausea G1/G2 (MG 48.4% vs CG 74.6%; 95% CI 0.48–0.87; p=0.002), vomiting G1/G2 (MG 8.1% vs CG 21.1%; 95% CI 0.15–0.99; p=0.036), polyneuropathy G1/G2 (MG 29.0% vs CG 49.3%; 95% CI 0.37–0.93; p=0.017) and mucositis/stomatitis G1/G2 (MG 21.0% vs CG 43.7%; 95% CI 0.28–0.83; p=0.006).
Conclusions: Postoperative enteral nutrition via microjejunostomy was associated with reduced postoperative weight loss, a smaller decrease in BMI and significantly reduced treatment-related toxicity. However, it did not increase the overall proportion of patients receiving adjuvant therapy.
Keywords: Gastric cancerGastrectomyEnteral nutritionMicrojejunostomyBody weight lossAdjuvant chemotherapy
66. Patterns and determinants of recurrence after curative-intent gastrectomy for gastric adenocarcinoma: a multicenter European study
Authors: Francesca Blasa1, Giuseppe Verlato2, Hidde Overtoom3, Martina Hermez Chole4, Fabrizio Tedone1, Federica Filippini1, Markos Despotidis5, Evgenia Mela6, Tania Triantafyllou6, Dimitrios Schizas5, Dimitrios Theodorou6, Magnus Nilsson4, Suzanne S. Gisbertz3, Maria Bencivenga1, Ioannis Rouvelas4,6.
Affiliation: 1.Upper GI Division, University of Verona, Verona, Italy. 2.Department of Diagnostics and Public Health, University of Verona, Verona, Italy. 3.Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands. 4.Karolinska University Hospital, Huddinge, Stockholm, Sweden.5.Laikon General Hospital, Athens, Greece.7.Hippocration General Hospital, Athens, Greece.
Introduction: Predictors of site-specific recurrence after curative-intent gastrectomy remain poorly defined in Western populations.
Objective: We evaluated the impact of Lauren histology on recurrence patterns and survival.
Methodology: Retrospective multicentre study of 958 patients undergoing curative-intent gastrectomy for gastric adenocarcinoma (2015–2023) at five European high-volume centres. Overall survival was assessed in 931 patients; disease-free survival and recurrence analyses in 896. Recurrence was classified as local, nodal, peritoneal, liver, lung, bone, or other distant. Logistic regression and Cox models evaluated the prognostic impact of Lauren histology after adjustment for clinicopathological factors.
Results: Median follow-up was 42.5 months. Recurrence occurred in 315/896 patients (35.2%), differing by histology: intestinal 29.0%, diffuse 42.2%, mixed 37.0% (P=0.001). Five-year overall survival was lower in diffuse and mixed than intestinal tumours, but this effect disappeared after adjusting for pT and pN. Diffuse tumours showed more peritoneal (27.3%), local (10.2%), and bone (5.1%) recurrence; intestinal tumours more frequently developed liver recurrence (11.1%). Nodal recurrence was unrelated to Lauren histology but rose with pN stage (3.3% to 23.6%, P<0.001). Neoadjuvant chemotherapy was linked to higher crude recurrence (39.4% vs 30.7%, P=0.006), particularly peritoneal (20.5% vs 13.3%, P=0.004), likely reflecting treatment-selection bias; it was not independently associated with survival (HR 1.09, 95% CI 0.86–1.38). R1 resection markedly increased recurrence (66.7% vs 33.1%, P<0.001), especially local (20.4% vs 6.7%) and peritoneal (40.7% vs 15.5%) recurrence.
Conclusions: Recurrence after curative-intent gastrectomy follows distinct patterns shaped by Lauren histology, nodal burden, resection status, and treatment selection, supporting histology-informed surveillance and careful patient selection for multimodal treatment.
Keywords: Gastric cancer; Lauren classification; Recurrence; Survival; Neoadjuvant chemotherapy
67. Total Gastrectomy for Life-Threatening Upper Gastrointestinal Bleeding in an Intestinal Transplant Recipient with Gardner Syndrome
Authors: Bruno Matos Santos, Mickael Chevallay, Stefan Mönig
Affiliation: Division of Visceral Surgery, Department of Surgery, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
Introduction: Gardner syndrome is a phenotypic variant of familial adenomatous polyposis that may be associated with extensive upper gastrointestinal polyposis. Management of severe gastrointestinal bleeding is particularly challenging in intestinal transplant recipients because of immunosuppression, altered anatomy, previous abdominal surgery, and limited endoscopic access.
Objective: To report the multidisciplinary management of life-threatening upper gastrointestinal bleeding requiring total gastrectomy in an intestinal transplant recipient with Gardner syndrome, followed by recurrent bleeding from an excluded duodenal segment.
Methodology: We present a single-patient case based on clinical, endoscopic, radiological, operative, histopathological, nuclear medicine, and interventional radiology findings.
Results: A man in his late 50s with Gardner syndrome had previously undergone total colectomy and intestinal transplantation for an invasive mesenteric desmoid tumor. Shortly after subsequent kidney transplantation, while receiving immunosuppressive therapy, he developed recurrent melena, tachycardia, and transfusion-dependent anemia. Upper gastrointestinal endoscopy demonstrated numerous friable gastric polyps with diffuse contact bleeding and multiple punctate hemorrhagic sites. Repeated endoscopic treatment failed to achieve durable hemostasis, while computed tomography showed no active arterial extravasation.Because of persistent life-threatening upper gastrointestinal bleeding, total gastrectomy with Roux-en-Y esophagojejunostomy was performed despite extensive adhesions and complex post-transplant anatomy. Histopathological examination identified more than 100 gastric polyps, including hyperplastic, fundic-gland, pyloric-gland adenomatous, and tubular adenomatous lesions. Dysplasia was limited to low grade, with no invasive carcinoma.Postoperatively, melena and severe anemia recurred. Endoscopy demonstrated a healthy esophagojejunal anastomosis and no bleeding within the accessible jejunal limb; however, the excluded duodenum could not be reached. Dynamic 99mTc-labelled red-blood-cell scintigraphy with SPECT/CT localized active bleeding to the excluded duodenal stump. Transhepatic portal venography identified intramural duodenal varices, which were successfully embolized using coils and ethylene-vinyl alcohol copolymer. Bleeding ceased, hemoglobin stabilized, and therapeutic anticoagulation could subsequently be resumed.
Conclusions: Total gastrectomy provided definitive treatment for uncontrolled upper gastrointestinal bleeding caused by extensive gastric polyposis in an intestinal transplant recipient with Gardner syndrome. Persistent bleeding after reconstruction should raise suspicion of an inaccessible excluded gastrointestinal segment. In this setting, radionuclide scintigraphy with SPECT/CT can localize an occult bleeding source and guide targeted interventional treatment.
Keywords: Gardner syndrome; intestinal transplantation; upper gastrointestinal bleeding; gastric polyposis; total gastrectomy; duodenal varices; SPECT/CT