Annual Report 2022

Department of Gastric Surgery

Takahiro Kinoshita, Masahiro Yura, Eigo Akimoto, Mitsumasa Yoshida, Takafumi Okayama, Yuya Takabe, Takumi Habu, Hiromi Nagata, Masaru Komatsu, Daiki Terajima

Introduction

 Our department consists of three staff surgeons and seven junior surgeons. Our managing of tumors includes common gastric adenocarcinoma, adenocarcinoma of the esophagogastric junction (AEG: Siewert type 2/3), and gastric submucosal tumors (GIST, etc.). In 2022, we performed gastrectomy on 227 patients, either using open surgery, laparoscopic or robotic surgery (Table 1). Laparoscopic gastrectomy was introduced in 2010, while robot-assisted gastrectomy was implemented in 2014. This year, more than 90% of gastrectomy was performed under laparoscopy or was robot-assisted (Table 2). The basis of our surgery is radical extirpation of cancer lesions with nodal dissection; however, simultaneously, organ functions and better quality of life (QOL) should be maintained. Additionally, we strive to obtain better clinical outcomes for patients with diseases with dismal prognoses (type 4 gastric cancer or with progressive metastasis) through surgery combined with a modern perioperative chemotherapy in cooperation with medical oncologists.

The Team and What We Do

 Usually, 10-14 patients are hospitalized and five to seven patients undergo operations per week. Our department conducts clinical conferences weekly to decide on our treatment strategies. Further, a conference with internal medicine is held weekly including doctors from Medical Oncology and Gastrointestinal Endoscopy, to discuss accurate diagnosis of the patients to decide the optimal treatment method. Robot/laparoscopic surgery covers distal, proximal, pylorus-preserving, and total gastrectomy. D2 dissection can also be performed, with indication extending to locally advanced cancer or cancer after NAC. Recently, due to the progress of chemotherapy regimen, down-staging from cStageIV is sometimes seen. For such patients, we selectively perform conversion surgery to achieve favorable outcomes. For AEGs, the transhiatal approach or thoraco-laparoscopic Ivor-Lewis surgery can be performed by minimally invasive means.

Research Activities

 We aggressively publish our clinical research data at domestic or international congresses. Additionally, we participate in multi-institutional clinical trials conducted by the Japan Clinical Oncology Group (JCOG) – Gastric Surgery Study Group or other international and domestic organizations, and work as PI for some clinical trials (JCOG1809) (COSMOS-GC regarding liquid biopsy). We have started investigating the auto intelligence technology relevant to laparoscopic or robot-assisted surgery.

Clinical Trials

 The list of multi-institutional clinical trials we participated in is shown below.

1) JCOG1301C A randomized phase II study of sysemic chemotherapy with and without trastuzumab followed by surgery in HER2 positive advanced gastric or esophagogastric junction adenocarcinoma with extensive lymph node metastasis (Trastuzumab In Gastric or Esophagogastric junction Adenocarcinoma)

2) JCOG1509 Phase III trial to evaluate the efficacy of neoadjuvant chemotherapy with S-1 plus oxaliplatin followed by D2 gastrectomy with adjuvant S-1 in locally advanced gastric cancer (NAGISA trial)

3) JCOG1809 Single-arm phase II trial to evaluate safety of Laparoscopic Total Gastrectomy with Spleen-PReservING splenic hilar dissection for proximal gastric cancer invading the greater curvature (LTG-SPRING-PII)

4) JCOG1907 Randomized controlled phase III trial to investigate superiority of robot-assisted gastrectomy over laparoscopic gastrectomy for clinical stage T1-2N0-2 Gastric Cancer patients (MONA-LISA Study)

5) A Phase III, Randomized, Double-Blind, Clinical Trial of Pembrolizumab (MK-3475) Plus Chemotherapy (XP or FP) Versus Placebo Plus Chemotherapy (XP or FP) as Neoadjuvant/Adjuvant Treatment for Subjects With Gastric and Gastroesophageal Junction (GEJ) Adenocarcinoma (KEYNOTE-585)

6) An open label phase 2 study to evaluate the safety and efficacy of lenvatinib with pembrolizumab in the neoadjuvant / adjuvant treatment for patients with gastric cancer (EPOC2001)

7) An open label phase 2 study to evaluate the efficacy and safety of trastuzumab deruxtecan (T-DXd) in the neoadjuvant treatment for patients with HER2 positive gastric and gastroesophageal junction adenocarcinoma (EPOC2003)

8) Multiomics data cancer diagnostics therapies (TITANIA Study)

9) Conquer Solid Malignancies by blood screening –gastric cancer- 01 (COSMOS-GC-01)

10) Development of a Clinical Decision Support System (CDSS) with Artificial Intelligence for Gastric and Esophageal Adenocarcinomas (Ask Bob Study)

11) The HOLD Study– StomacH Cancer Elective Surgery MOrbidity and Mortality at 90-Day / The OUTLIVE Study - Oesophageal and JUncTional Cancer ELectIVE Surgery Morbidity and Mortality at 90-Day: A TUGS Multinational Audit

12) The UGIRA International Registry for Robot-Assisted Minimally Invasive Gastrectomy (RAMIG) for gastric cancer

13) The UGIRA International Registry for Robot-Assisted Minimally Invasive Esophagectomy (RAMIE)

Education

 Resident doctors are trained to become specialized surgical oncologists with sufficient techniques and knowledge. Nowadays, these doctors are given opportunities to perform laparoscopic/open/robotic surgeries. We also place importance on the education of surgeons of other institutions. In 2022, we could only accept a few foreign doctors due to the COVID-19 pandemic, but many more candidates hope to visit our department and thus we have resumed admissions since the beginning of 2023. We are endorsed as an officially certified institution for surgery observation of robotic gastrectomy.

Future Prospects

 We will keep striving to obtain better survival outcomes for patients with far-advanced diseases; for multidisciplinary therapy (chemotherapy, molecular-target agents or immune oncology agents), collaborating with medical oncologists is essential. Additionally, we will continue to develop less-invasive surgical methods (laparoscopic or robotic surgery), to improve patients’ QOL and achieve complete cures. It is also our obligation to expand our knowledge and experience globally as one of the main countries in terms of incidence of gastric cancer.

List of papers published in 2022

Journal

1. Akimoto E, Kinoshita T, Sato R, Yura M, Harada J, Yoshida M, Okayama T, Takabe Y, Tanaka Y, Tomi Y, Habu T. Impact of postoperative intra-abdominal infectious complications on survival outcomes in patients with gastric cancer who underwent laparoscopic surgery. Surgical endoscopy, 37:382-390, 2023

2. Kanda M, Terashima M, Kinoshita T, Yabusaki H, Tokunaga M, Kodera Y. A multi-institutional study to evaluate the feasibility of next-generation sequencing and genomic analysis using formalin-fixed, paraffin-embedded biopsies of gastric cancer. Gastric cancer, 26:108-115, 2023

3. Kinoshita T, Akimoto E, Yura M, Yoshida M. Survival outcomes of laparoscopic versus open total gastrectomy with nodal dissection for gastric cancer in a high-volume Japanese center: A propensity score-matched analysis. Annals of gastroenterological surgery, 7:53-62, 2023

4. Yamaguchi T, Takashima A, Nagashima K, Kumagai K, Yamada T, Terashima M, Yabusaki H, Nishikawa K, Tanabe K, Yunome G, Kawachi Y, Yamada T, Fukagawa T, Kinoshita T, Watanabe M, Ishiyama K, Inoue K, Boku N. Evaluating the efficacy of post-operative chemotherapy after curative resection of stage IV gastric cancer with synchronous oligo metastasis: a multicenter retrospective study. Gastric cancer, 26:307-316, 2023

5. Habu T, Kumanishi R, Ogata T, Fujisawa T, Mishima S, Kotani D, Kadowaki S, Nakamura M, Hojo H, Fujiwara H, Kumagai S, Koyama S, Fujita T, Kinoshita T, Nishikawa H, Yano T, Tajika M, Muro K, Mitsunaga S, Kojima T, Bando H. Complete response to definitive chemoradiotherapy in unresectable locally advanced esophageal squamous cell carcinoma. Esophagus, 20:533-540, 2023

6. Sakashita S, Sakamoto N, Kojima M, Taki T, Miyazaki S, Minakata N, Sasabe M, Kinoshita T, Ishii G, Ochiai A. Requirement of image standardization for AI-based macroscopic diagnosis for surgical specimens of gastric cancer. Journal of cancer research and clinical oncology, 2023

7. Etoh T, Ohyama T, Sakuramoto S, Tsuji T, Lee SW, Yoshida K, Koeda K, Hiki N, Kunisaki C, Tokunaga M, Otsubo D, Takagane A, Misawa K, Kinoshita T, Cho H, Doki Y, Nunobe S, Shiraishi N, Kitano S. Five-Year Survival Outcomes of Laparoscopy-Assisted vs Open Distal Gastrectomy for Advanced Gastric Cancer: The JLSSG0901 Randomized Clinical Trial. JAMA surgery, 158:445-454, 2023

8. Akimoto E, Kuwata T, Shitara K, Kawazoe A, Sakamoto N, Ishii G, Ochiai A, Kinoshita T. Impact of Programmed Death-Ligand 1 Expression on Mismatch Repair Deficiency and Epstein-Barr Virus Status on Survival Outcomes in Patients with Stage II/III Gastric Cancer After Surgery. Annals of surgical oncology, 2023

9. Mizusawa J, Tokunaga M, Machida N, Yabusaki H, Kawabata R, Imamura H, Kinoshita T, Nomura T, Nunobe S, Tsuji K, Katayama H, Fukuda H, Boku N, Yoshikawa T, Terashima M, Stomach Cancer Study Group of the Japan Clinical Oncology Group. Protocol digest of a phase III trial to evaluate the efficacy of preoperative chemotherapy with S-1 plus oxaliplatin followed by D2 gastrectomy with postoperative S-1 in locally advanced gastric cancer: Japan Clinical Oncology Group study JCOG1509 (NAGISA Trial). Japanese Journal of Clinical Oncology, 53:168-173, 2022

10. Ikematsu H, Ishihara M, Okawa S, Minamide T, Mitsui T, Kuwata T, Ito M, Kinoshita T, Fujita T, Yano T, Omori T, Ozawa S, Murakoshi D, Irisawa K, Ochiai A. Photoacoustic imaging of fresh human surgically and endoscopically resected gastrointestinal specimens. DEN open, 2:e28, 2022

11. Tanaka Y, Kinoshita T, Akimoto E, Sato R, Yura M, Harada J, Yoshida M, Tomi Y. The impact of hiatal hernia on survival outcomes in patients with gastroesophageal junction adenocarcinoma. Annals of gastroenterological surgery, 6:366-374, 2022

12. Komatsu M, Kinoshita T, Akimoto E, Yoshida M, Terajima D, Nagata H, Habu T, Okayama T, Takabe Y, Harada J, Yamaguchi M, Yura M. The Significance of Staging Laparoscopy in Detection of Radiologically Occult Peritoneal Carcinomatosis in Gastric Cancer With Gastric Outlet Obstruction: Consideration of The Optimal Treatment Approach. Anticancer research, 42:5571-5578, 2022