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COMPARING THE TREATMENT BURDEN OF MINIMALLY-INVASIVE AND OPEN GASTRECTOMY AFTER NEOADJUVANT CHEMOTHERAPY FOR LOCALLY-ADVANCED GASTRIC CANCER
Ana Sofia Ore*1, Courtney E. Barrows1, Andrea Bullock2, Jonathan F. Critchlow3, A. J. Moser1
1The Pancreas and Liver Institute, Beth Israel Deaconess Medical Center , Boston, MA; 2Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston, MA; 3Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
Background/Aims: While minimally invasive gastrectomy is superior to an open approach in early gastric cancer, its relative performance in locally-advanced disease remains unclear. Complete surgical resection after neoadjuvant chemotherapy (NAC) offers the best long-term survival for locally-advanced gastric cancer (LAGC). Furthermore, emerging data indicate that extended (D2) lymphadenectomy positively impacts survival if low perioperative morbidity is maintained. We hypothesized that robot-assisted D2 gastrectomy will reduce cumulative treatment burden without compromising oncologic efficacy after neoadjuvant chemotherapy in patients with locally advanced gastric cancer.
Methods: Single institution retrospective analysis of all patients with locally-advanced gastric cancer (T3-4N0 or Tany N+) who received ≥ 1 dose of neoadjuvant chemotherapy followed by curative-intent open or robotic gastrectomy from 2006-2016. Treatment burden was assessed using a composite primary outcome of adverse events, which required at least one of the following: transfusion within 72 hours of surgery; lymph node harvest<20; positive surgical resection margin (R1 or R2); cumulative 90-day morbidity ≥ Clavien-Dindo IIIA (Comprehensive Complication Index>26.2), and index length of stay exceeding 10 days (75th percentile).
Results: Of the 42 subjects with locally-advanced gastric cancer who received neoadjuvant chemotherapy with curative-intent, nine progressed (22%) detected by preoperative imaging (5) or during staging laparoscopy (4). 17 robotic (51.5%) and 16 (48.5%) open gastrectomies were performed before and after universal institutional adoption of robotic D2 gastrectomy. Demographic characteristics, tumor size, location, and AJCC stage were equivalent between groups. There were no conversions to open despite including the entire robotic learning curve. Adverse composite outcomes were more likely after open gastrectomy than robotic (Table 1). 93.7% (15/16) of subjects met criteria for the composite adverse outcome after open gastrectomy compared to 58.8% (10/17) after the robotic approach (Fisher’s Exact p<0.039). Patients undergoing robotic gastrectomy realized a 37% reduced risk for composite adverse outcome compared to open (RR 0.63; 95% CI 0.41-0.95).
Conclusions: We conclude that robotic D2 gastrectomy after neoadjuvant chemotherapy may reduce cumulative treatment burden without compromising oncological outcomes compared to open gastrectomy among patients with locally-advanced gastric cancer. The treatment groups were equivalent with respect to potential selection factors within the confines of a nonrandomized comparison. Phase III clinical trials are needed to validate these data.
Composite Adverse Outcome
| | Open
Gastrectomy
(N=16) | Robot Assisted
Gastrectomy
(N= 17) | | No Negative Outcomes | 1 (6.2%)
| 7 (41.1%)
| Transfusion within 72 hours
| 3 (18.7%)
| 1 (5.8%)
| | <20 lymph nodes | 9 (56.2%) | 7 (41.1%)
| | Positive Margin (R1 or R2) | 3 (18.7%)
| 2 (11.7)
| | Comprehensive Complication Index > 26.2 (90 day) | 4 (25%)
| 3 (17.6%)
| | Length of Stay > 10 days | 5 (31.2%)
| 3 (17.6%)
| Composite Negative Outcome
| 15 (93.7%)
| 10 (58.8%)
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