Management, outcome and prognostic factors of metastatic gastric cancer
Authors: S. Karrit, I. Belaid, F. Ezzairi, A. El Ghali, A. Bedioui, N. Bouzid, M. Ben Mabrouk, F. Bouzaiene, Y. Ben Cheikh, I. Chabchoub, M. Hochlaf, L. Ben Fatma, S. Ben Ahmed
Journal: Annals of Oncology (2018)

Introduction: Patients with gastric cancer are usually diagnosed at an advanced stage. Metachronous metastases are also frequent. Survival rates of metastatic gastric cancer remain poor. Identifying prognostic factors is necessary to improve current treatment approaches. Methods: This is a retrospective study carried out in a department of medical oncology in Tunisia between 2010 and 2017. 115 patients were treated for gastric cancer. Patients with synchronous or metachronous metastases of gastric cancer were included. We aim to analyse management of these patients, their outcome and prognostic factors. Results: A total of 74 patients (64.3%) were studied. Median age was 55 years old [26-85] with a male predominance (60.8%). Median time to diagnosis was 3 months and main complaint was epigastric pain (53.5%). 63% of patients had good performance status [0-1]. Most tumors were proximal (56.2%). Adenocarcinoma (94.6%) was the most common histological type with a poor differentiation in 58.5%. 68.5% of the patients were metastatic at diagnosis, 24% developed experienced metastases during or after neo adjuvant treatment and the other were metachronous. The most common sites of metastases were the peritoneum (65.8%), followed by the liver (36.6%) and the lungs (26.4%). 52.7% of patients had surgery from whom 47.7% had a palliative surgery. Digestive derivation was done in 12.8% of cases. Hepatic metastasectomy was performed in one patient. 92.2% of our patients received a first line chemotherapy. LV5 FU2-CISPLATIN, FOLFOX and DCF were the most frequently used regimens (respectively 58.7%, 13% and 8.7%). 54.8% of patients progressed, 13% had a stable disease, 29% experienced a partial radiological response and 13% experienced a complete response. All complete responses were reported after treatment by LV5 FU2 CISPLATIN (p = 0.2). However, FOLFOX allowed better disease control rate (partial remission and stability) than LV5 FU2 CISPLATIN and DCF (respectively 50%, 47.1% and 33.3%; p = 0.9). 23.4% of patients received second line treatment. The two most commonly used regimens were FOLFIRI (36.4%) and Capecitabine (27.3%). FOLFIRI seemed to be more effective than Capecitabine (respectively 66.7% of progression vs 100%, p = 0.5). Only 4.3% of patients received a third line chemotherapy based on capecitabine or FOLFIRI. All patients progressed. The median number of received chemotherapy cycles was 4. 41.9% of our patients developed grade 3-4 toxicity during chemotherapy. There was no treatment-related death. Median overall survival (OS) and progression free survival (PFS) were respectively 6 and 5 months. On univariate analysis, factors associated with poor OS were elevated tumor markers (p = 0.001), hepatic metastases (p = 0.003) and radiologic progression after first line treatment (p = 0.03). Those related with a better survival were receiving first (p<0.001) and second line chemotherapy (p = 0.01) and having a surgery (p = 0.01) even with a palliative intent (p = 0.04). Multivariate analysis demonstrated that the only independent factor positively impacting on survival was receiving chemotherapy (p = 0.01). Conclusion: Metastatic spread of gastric cancer is fatal. This study confirms the survival benefit and manageable toxicity of palliative chemotherapy but survival increase remains poor compared to improvements in other gastrointestinal cancers.