Prognostic significance of peritoneal lavage cytology in staging gastric cancer: systematic review and meta-analysis

Gastric Cancer, Aug 2017

Background Peritoneal cytology has been used as a part of the cancer staging of gastric cancer patients. The primary aim of this systematic review was to evaluate the value of peritoneal cytology as part of the staging of gastric cancer and survival prediction. The second aim was to establish if positive cytology may be modified by neoadjuvant therapy, to improve prognosis. Methods An electronic literature search was performed using Embase, Medline, Web of Science, and Cochrane library databases up to January 2016. The logarithm of the hazard ratio (HR) with 95% confidence intervals (CI) was used as the primary summary statistic. Comparative studies were used, and the outcome measure was survival in three groups: (1) positive versus negative cytology at staging laparoscopy immediately preceding surgery; (2) effect of neoadjuvant therapy on cytology and survival; and (3) positive cytology in the absence of macroscopic peritoneal disease was compared with obvious macroscopic peritoneal disease. Results Pooled analysis demonstrated that positive cytology was associated with significantly reduced overall survival (HR, 3.46; 95% CI, 2.77–4.31; P < 0.0001). Interestingly, negative cytology following neoadjuvant chemotherapy was associated with significantly improved overall survival (HR, 0.42; 95% CI, 0.31–0.57; P < 0.0001). The absence of macroscopic peritoneal disease with positive cytology was associated with significantly improved overall survival (HR, 0.64; 95% CI, 0.56–0.73; P < 0.0001). Conclusion This study suggests that patients with initial positive cytology may have a good prognosis following neoadjuvant treatment if the cytology results change to negative after treatment.

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Prognostic significance of peritoneal lavage cytology in staging gastric cancer: systematic review and meta-analysis

Prognostic significance of peritoneal lavage cytology in staging gastric cancer: systematic review and meta‑analysis Sara Jamel 0 Sheraz R. Markar 0 George Malietzis 0 Amish Acharya 0 Thanos Athanasiou 0 George B. Hanna 0 0 Department of Surgery and Cancer, Imperial College London, 10th Floor QEQM Building, St Mary's Hospital , South Wharf Road, London W2 1NY , UK 1 George B. Hanna Background Peritoneal cytology has been used as a part of the cancer staging of gastric cancer patients. The primary aim of this systematic review was to evaluate the value of peritoneal cytology as part of the staging of gastric cancer and survival prediction. The second aim was to establish if positive cytology may be modified by neoadjuvant therapy, to improve prognosis. Methods An electronic literature search was performed using Embase, Medline, Web of Science, and Cochrane library databases up to January 2016. The logarithm of the hazard ratio (HR) with 95% confidence intervals (CI) was used as the primary summary statistic. Comparative studies were used, and the outcome measure was survival in three groups: (1) positive versus negative cytology at staging laparoscopy immediately preceding surgery; (2) effect of neoadjuvant therapy on cytology and survival; and (3) positive cytology in the absence of macroscopic peritoneal disease was compared with obvious macroscopic peritoneal disease. Results Pooled analysis demonstrated that positive cytology was associated with significantly reduced overall survival (HR, 3.46; 95% CI, 2.77-4.31; P < 0.0001). Interestingly, negative cytology following neoadjuvant chemotherapy was associated with significantly improved overall survival (HR, 0.42; 95% CI, 0.31-0.57; P < 0.0001). The absence of macroscopic peritoneal disease with positive cytology was associated with significantly improved overall survival (HR, 0.64; 95% CI, 0.56-0.73; P < 0.0001). Gastric cancer; stomach neoplasm; Laparoscopy; Peritoneal cytology; Cancer staging; Cancer prognosis - Conclusion This study suggests that patients with initial positive cytology may have a good prognosis following neoadjuvant treatment if the cytology results change to negative after treatment. Introduction The main treatment of advanced nonmetastatic gastric cancer is surgical resection with perioperative chemotherapy or chemoradiotherapy [ 1, 2 ]. Efforts to prolong survival in metastatic gastric cancer have showed little improvement [ 1, 2 ]. Accurate staging of gastric cancer is crucial in selecting the appropriate treatment option, whether curative or palliative. The Japanese Gastric Cancer Association included the results of cytological examination of peritoneal lavage fluid as a key prognostic factor in their classification of gastric carcinoma [ 1, 3 ]. However, recently published guidelines suggested that cytology-positive status in the absence of other noncurative factors, that is, macroscopic disease, can be managed with D2 gastrectomy and perioperative chemotherapy [4]. Initial data of those treated with surgery alone showed poor 5-year survival; however, more recent publications have shown that the use of postoperative chemotherapy improves overall survival rates to 26%, [ 5, 6 ]. On the other hand, if the information on cytology status were available before surgery, a chemotherapy-first strategy could be taken whereby patients whose cytology status turned negative could be preferentially treated with curative surgery [ 7, 8 ]. The incidence of positive peritoneal cytology for patients with gastric cancer varies, in published reports, from 4% to 41% [ 9 ]. Peritoneal washings positive for cancer cells have been demonstrated to correlate with the extent of cancer (T1/ T2, 0%; T3/T4, 10%; M+, 59%) [ 10 ] and have been considered as stage IV disease [ 11 ]. The influence of positive cytology on survival has been shown as a powerful independent predictor of survival when compared to other postoperative pathological variables such as the tumor serosal invasion or lymph node involvement [ 2, 6, 12, 13 ]. Positive cytology was shown to be the most powerful predictor of outcome, with a risk ratio of 2.7 for patients undergoing curative resection [2]. Furthermore, studies have also shown that the number and arrangement of cytology-positive cells have an effect on survival at the time of gastrectomy [ 10, 12 ]. The results of the randomized controlled trial by the apan Clinical Oncology Group (JCOG 0705) and Korea Gastric Cancer Association (KGCA01), comparing gastrectomy plus chemotherapy versus chemotherapy alone in advanced gastric cancer with a single noncurable factor, showed no advantage of resecting the primary gastric cancer in the presence of peritoneal metastasis [ 11 ]. Nevertheless, the treatment recommendations for gastric cancer in the event of positive cytology range from palliative chemotherapy to attempts at neoadjuvant therapy followed by surgical resection [ 4, 14 ]. The aim of this study w (...truncated)


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Sara Jamel, Sheraz R. Markar, George Malietzis, Amish Acharya, Thanos Athanasiou, George B. Hanna. Prognostic significance of peritoneal lavage cytology in staging gastric cancer: systematic review and meta-analysis, Gastric Cancer, 2017, pp. 1-9, DOI: 10.1007/s10120-017-0749-y