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IDENTIFYING CLINICAL AND PATHOLOGICAL FACTORS ASSOCIATED WITH UPSTAGING IN GASTRIC CANCER
Judy Li
*, Nazanin Khajoueinejad, Allen T. Yu, Josh Kim, Spiros Hiotis, Noah A. Cohen, Camilo Correa-Gallego, Joshua Leinwand, James O. Park, Neha L. Lad
Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
Introduction Appropriate clinical staging helps guide management towards upfront surgery versus perioperative therapy in gastric cancer. However preoperative imaging demonstrates some inaccuracies especially with nodal staging. We investigate clinical and pathological characteristics associated with upstaging in gastric cancer that may help guide clinical decision making.
Methods A retrospective study was conducted on gastric cancer patients who underwent curative-intent surgery at a single tertiary care institution between 2010 and 2022. All patients with data available for pre-operative endoscopic ultrasounds (EUS) and abdominopelvic imaging were included. Patients upstaged on N or T stage on final pathology were compared to those who were not. Primary and secondary outcomes were differences in clinical and pathologic characteristics between upstaged and non-upstaged patients.
Results Preoperatively 178 patients had both EUS and CT imaging completed. 43 patients (24%) had their nodal status upstaged on final pathology and 49 (28%) had pT upstaged. Patients with nodal upstaging had similar EUS T and N clinical staging compared to those not upstaged. However, these patients more frequently had visible masses on preoperative CT (63% vs 42%) and displayed significantly higher rates of lymphovascular invasion (79% vs 19%), perineural invasion (65% vs 18%), and poor differentiation (86% G3 vs 49%, all P<0.05). While the majority of these patients were identified as cN0 preoperatively (65%), 72% were identified to have pN2 and pN3 disease. There were also higher rates of pT upstaging (56% vs 19%, P<.001) when N stage was upstaged. In a second analysis comparing patients with pT upstaged versus those who weren’t, those upstaged more frequently had visible masses identified on CT (59% vs 43%), higher rates of lymphovascular invasion (63% vs 23%), perineural invasion (63% vs 16%,), signet ring cells (55% vs 39%,), and poor differentiation (84% G3 vs 48%, all P<0.05). A subset analysis of patients who were identified to have no nodal disease on both EUS and CT (N=87) was conducted. On final pathology 22 patients (25%) had nodal upstaging. Of these patients, 16 (73%) had lymphovascular invasion, 12 (55%) had perineural invasion, and 21 (95%) had moderate to poor differentiation.
Conclusion In gastric cancer there are significant rates of upstaging on final pathology. Even patients who were identified to have no evidence of nodal disease on both preoperative imaging and EUS demonstrated significant rates of nodal upstaging and associations with worse histological characteristics. Thorough review of CT imaging findings and presence of worse histopathological characteristics on preoperative biopsy should be taken into consideration for optimal oncologic treatment of gastric cancer patients.
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