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Metastatic Gastric Cancer (MGC) Patients: Can WE Improve Survival by Metastasectomy? a Systematic Review and Meta-Analysis
Rahul Gadde*1, 2, Leonardo Tamariz2, Mena Hanna1, Dido Franceschi1, Alan S. Livingstone1, 3, Danny Yakoub1, 3
1Division of Surgical Oncology at Department of Surgery, University of Miami-Miller School of Medicine, Miami, FL; 2Department of Internal Medicine, University of Miami-Miller School of Medicine, Miami, FL; 3Sylvester Comprehensive Cancer Center, University of Miami-Miller School of Medicine, Miami, FL
BACKGROUND: Prognosis for M1 gastric cancer patients with current management strategies continues to be dismal. We aimed to evaluate the role of metastasectomy in improving survival.
METHODS: A search of PubMed, MEDLINE, EMBASE, SCOPUS, and COCHRANE databases (1965 to present) with review of key bibliographies was conducted. All studies comparing survival in M1 gastric cancer patients undergoing metastasectomy vs. other therapies were included; quality was assessed using the STROBE checklist. Pooled risk ratio along with the 95% confidence interval (CI) for survival at 1, 3, and 5 years were calculated.
RESULTS: The search strategy yielded 97 articles, of which 16 articles met our selection criteria. The studies included total of 1712 patients, 378 patients underwent metastasectomy while 1334 underwent other palliative modalities. Median age was 63 years. Male /female ratio was 3 to1. Meta-analysis of included data showed significantly increased survival in patients undergoing metastasectomy compared with those undergoing other therapies at: 1-YR (RR 0.48, CI 0.41 - 0.56), 3-YR (RR 0.73, CI 0.68 - 0.73), and 5-YR (RR 0.83, CI 0.78 - 0.88); the mean increased difference in survival conferred by metastasectomy averaged between 9.3-15.7 months; p<0.001 for all results. Age, ECOG status and STROBE score did not contribute to differences in survival.
CONCLUSIONS: Metastasectomy is associated with increased survival at 1, 3, and 5 years in patients with M1 gastric cancer. The results should be viewed with caution since all the studies were retrospective. Large randomized controlled trials are critically needed to evaluate metastasectomy for patients with metastatic gastric cancer.
Table 1: Characteristics and primary outcomes of the included studies
| Author | Year | STROBE score | Number of patients (N) | Survival (%) | Median survival time (months) | Adjuvant chemotherapy | Median follow-up (months) | | 1-year | 3-year | 5-year | | | | Total | M | NM | M | NM | M | NM | M | NM | M | PG | CH | | | | Tiberio et al.17 | 2014 | 29 | 195 | 53 | 142 | 45% | 13% | 11% | 1% | 8% | 1% | 13.0 | 6.6 | 3.0 | ± | 15.0 | | Mohri et al.18 | 2014 | 25 | 123 | 28 | 95 | 64% | 32% | 21% | 3% | 7% | 2% | 21.9 | 12.5 | 7.2 | ± | 9.3 | | Yang et al.19 | 2013 | 21 | 89 | 30 | 59 | 70% | 58% | 23% | 8% | 20% | 7% | 14.5 | 13.5 | NA | + | 14.9 | | Chen L et al.20 | 2013 | 22 | 114 | 20 | 94 | 70% | 14% | 20% | 0% | 20% | 0% | 22.3 | NA | 5.5 | ± | 10 | | Chen S et al.21 | 2012 | 24 | 160 | 25 | 135 | 100% | 48% | 32% | 0% | 0% | 0% | 28.9 | 18.5 | 13.8 | - | 8.7 | | Miki et al.22 | 2012 | 25 | 50 | 25 | 25 | 72% | 44% | 44% | 20% | 36% | 8% | 33.4 | 10.5 | 8.7 | + | 17.5 | | Lin et al.23 | 2012 | 24 | 105 | 35 | 70 | 57% | 33% | 29% | 10% | 6% | 3% | 15.0 | 10.0 | NA | - | 11 | | Dittmar et al.24 | 2011 | 21 | 98 | 15 | 83 | 80% | 40% | 53% | 6% | 27% | 0% | 48.0 | NA | 9.0 | - | 11 | | Kim et al.25 | 2011 | 24 | 274 | 42 | 232 | 81% | 51% | 43% | 4% | 0% | 0% | 28.0 | 15.5 | 9.0 | ± | 10.2 | | Makino et al.26 | 2010 | 24 | 63 | 16 | 47 | 88% | 53% | 56% | 4% | 44% | 0% | 31.2 | 15.2 | NA | + | 16 | | Tiberio et al.27 | 2009 | 27 | 73 | 11 | 62 | 73% | 26% | 18% | 3% | 18% | 0% | 23.0 | 12.0 | 5.0 | ± | 15 | | Ueda et al.28 | 2008 | 26 | 26 | 15 | 11 | 80% | 36% | 60% | 0% | 60% | 0% | 24.0 | 9.0 | NA | ± | 13.4 | | Cheon et al.29 | 2008 | 26 | 58 | 41 | 17 | 76% | 29% | 32% | 0% | 20% | 0% | 20.0 | 8.1 | NA | ± | 15.5 | | Kunieda et al.30 | 2002 | 16 | 43 | 6 | 37 | 50% | 14% | 33% | 3% | 33% | 3% | 7.6 | 6.1 | 3.3 | ± | NA | | Takeda et al.31 | 1990 | 15 | 80 | 7 | 73 | 29% | 7% | 0% | 0% | 0% | 0% | 10.8 | 7.9 | 5.0 | - | NA | | Okuyama et al.32 | 1985 | 20 | 161 | 9 | 153 | 44% | 8% | 11% | 2% | 0% | 0% | 8.0 | 4.0 | 3.0 | ± | NA | | Total Publications: 16 | 23* | 1712 | 378 | 1334 | 67%* | 32%* | 32%* | 6%* | 25%* | 4%* | 21.9* | 10.7* | 6.6* | | 12.9* |
Abbreviations: M - Metastasectomy; NM - No-Metastasectomy; PG - Palliative Gastrectomy; CH - Chemotherapy; NA - Not available or applicable +: all patients received chemotherapy; -: chemotherapy was not given or mentioned; ±: a part of patients received chemotherapy *: Pooled average of data reported in the included studies  Figure 2. Metastasectomy vs No-metastasectomy for M1 gastric cancer patients - Forest plots showing survival outcomes at 1, 3, and 5 years
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