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Home  >  Medical Research Archives  >  Issue 149  > Staging I in a Gastric Adenocarcinoma Cohort
Published in the Medical Research Archives
Sep 2023 Issue

Staging I in a Gastric Adenocarcinoma Cohort

Published on Sep 28, 2023




Background: Gastric cancer was the fourth cause of cancer-related deaths in 2020 in the world. The aim of this study was to describe the characteristics of patients with gastric adenocarcinoma Stage I describing clinical, pathological, and neoadjuvant staging in a prospective cohort at A.C. Camargo Cancer Center (ACCCC).

Methods: Sixty-three patients with Stage I gastric adenocarcinoma treated at ACCCC were evaluated for clinical, pathological, and clinical Stages. For the comparison between the clinical staging and the post-treatment one (surgical and neoadjuvant): tumor (T) and lymph nodes (N) were evaluated.

Results: Of the 63 patients, 29/63 (46%) were clinical Stage I, and 34/63 (54%) were initially staged as clinical Stage II and III that migrated to Stage I after surgical and neoadjuvant treatment. As for the clinical aspects, 36/63 patients (57%) were men with an average age of 58.7 years, 63% patients were Caucasian and 83% (52) had private medical insurance. In the endoscopic reports, 68.3% (n=43) of the lesions were ulcerated and the histological type, 55.6% (n=35) were diffuse. Patients treated with neoadjuvant therapy had a 100% reduction of tumors T3/T4 to T1/T2 (p<0.001) and 78.5% of the regional lymph nodes, N+ to N0. (p=0.001).

Conclusion: The neoadjuvant therapy on patients with gastric adenocarcinoma led to significant tumor (T) and regional lymph nodes (N) regressions, thus, increasing the migration of cases from T3/T4 to T1 /T2 and N+ to N0 in this cohort.

Author info

Paola Arantes, Maria Paula Curado, Gisele Aparecida Fernandes, Tatiane Tiengo, Diego Rodrigues Mendonça E Silva, Felipe Coimbra, Vinícius Calsavara

The gastric cancer was the fifth most incident neoplasm worldwide in 2020, with 1,089,103 new cases and 684,996 deaths, representing 5.6% of incidence and 6.9% of cancer related deaths. In Brazil, in the same year, the estimated number of cases were 20,139, beinp 12,961 men and 7,178 women, becoming the fourth neoplasm more frequent in men (4.3%) and eiphth in woman (2.6%). About 95% of gastric cancer (GC) cases are adenocarcinomas, beinp more frequent in men and elderly2, and in Asian and Latin American population. The most frequent associated risks to gastric cancer are the infection of Helicobacter pylori, sodium rich diet, hiph consumption of red meat, smoking, the consumption of alcohol (above 37 prams/day) and obesity3.

The therapeutic plan for patients with gastric adenocarcinoma depends, besides the patient’s clinical performance, on the histological and clinical characteristics of the characterized by aggregating the characteristics according to the tumor (T), regional lymph nodes (N) and metastasis (M). Usually, patients are staged just after the diagnosis (clinical) and it again after treatment to verify its pathological details. Therefore, cancer staging is classified by three groups: clinical (cTN M), pathological (pTNM), referred to the patients that only underwent surgery and a third, (yTNM), referred to the patients that received neoadjuvant treatment and followed by a curative surgery4. The clinical staging  precedes  treatment, and it is based on the patient’s history and the imaging  exams  and  histological diagnosis. 4

The pathological staging is the macroscopic and microscopic exam of the surgical specimen (stomach) which describes the type of lesion (ulcerated, infiltrative, depressed, or elevated), the histological pattern, the safety margins and the presence of the regional lymph nodes infiltrated or not by the neoplasm. Regarding the neoadjuvant staging, the patient receives chemotherapy as before the main curative therapy (surgery), and the tumor is staged again through the surgical specimen, as to verify the local treatment response on the tumor and regional lymph nodes^.

Curative treatment for gastric cancer is surgery, including radical gastrectomy and postoperative chemotherapy, which are the standard treatments. However, surgery alone is not sufficient for the best survival outcomes^ 7. The MAGIC trial (2006) showed that neoadjuvant therapy,  administered before surgery, has emerged as a promising strategy to enhance tumor response rates, downstage tumors, and potentially improve long-term outcome than the patients with standard treatments. Neoadjuvant therapy (NAT) is a multimodal strategy developed to optimize prognosis and includes neoadjuvant chemotherapy (NACT), chemoradiotherapy (NACRT), targeted therapy and even immunotherapy 7.

The aim of the present study was to evaluate the sociodemographic, characteristics and clinical features regarding  the  impact  of pTN M and yTNM in patients with stage 01. By assessing the impact of neoadjuvant chemotherapy on tumor downstaging, pathologic response, and long-term survival outcomes, clinicians and researchers can guide treatment decisions, refine prognostic models, and identify patients who may require additional or alternative therapeutic interventions. This knowledge can aid in optimizing treatment protocols, reducing unnecessary surgeries, and improving overall patient outcomes.

This is a prospective cohort composed of sixty-three patients with gastric adenocarcinoma stage I, including pre and post treatment. This study is part of the case-control project named Epidemiology of Gastric Adenocarcinomas in Brazil conducted at the A.C. Camargo Cancer Center (ACCCC). The cases were patients with diagnose of gastric adenocarcinoma recruited from march of 2016 to august of 2019 at a single cancer center (ACCCC), of both genders and ages between 18 and 75 years. The patients with clinical or pathological stages II, Ill and IV were excluded from the analysis. 
The variables included in this study was: gender (male and female), age as continuous variable and stratified variables a60 or <60 years old, self-assigned ethnicity as Caucasian, African-descendent, brown, and Asian, the infection of H. pylori in endoscopic and pathological exams were characterized as positive and negative or not evaluated. Cases were staged according to the AJCC 8th edition\\\\\\\\\\\\\\\' and the histological classification applied was Laurens (1965)9. All cases were analyzed by relative and absolute frequencies in the program SPSS. To compare of pre- and post-treatment of T and N variables was utilized the chi-squared test.

In this prospective cohort of sixty-three patients in clinical, pathological, and neoadjuvant stage I, 36/63 (57%) were men with average age of 58.7 years with Caucasian self-identification ethnicity (63%). (Table 01) 

Repardinp  the access to treatment, 52/63 (83%) had medical insurance. The H. pylori infection was positive in 22% of cases (14/46) with the Giemsa diagnostic method more frequent 52% (33). Repardinp to the Lauren’s histological classification, the diffuse type was the more frequent 55.6% (n=35). (Table 02) 

Table 02. Clinical characteristics of sixty-three patients with gastric adenocarcinoma stage I at A.C.Camargo Cancer Center

Table 03. Endoscopic characterization and imaging description of sixty-three patients with gastric adenocarcinoma Stage I.

Of twenty-nine patients of clinical Stage I, 18/29 were men with ages below 60 years old (15/29). The most frequent lesion type found in the endoscopy was ulcerated and in the echo-endoscopy was depressed, with average size of 1.94cm. The intestinal histological type was the most found. In the CT SCAN there was not seen evidence of disease on 14/29 cases. In virtual gastroscopy, the gastric wall thickness of the gastric wall was found in all the cases. The presence of regional lymph nodes was not identified in this imaging exams. (Table 04)

Table 04. Clinical, histological, endoscopic, and imaging characterization of twenty- nine patients with gastric adenocarcinoma Clinical Stage I.

In 22 patients with pathological staging I (pTNM), it was observed the same age distribution under and above 60 years old (11/22). For the patients with neoadjuvant staging I (yTNM), it was most frequent in patients above 60 years old (25/38). Regarding the histological classification, the intestinal type was more found on the pTN M I group, and the diffuse type on the yTNM patients. (Table 05).

Table 05. Pathological (pTNM) and neoadjuvant (yTNM) staging of 60 patients with gastric adenocarcinoma.

When compared the clinical Stage of gastric adenocarcinoma with the pathological Stage, the anatomopathological examination of the surgical specimen identified that 12/16 patients continued to be T1/T2 staging, and 4/16 were TOO Regarding the T3/T4 staging, 100% (n=6), after surgery were found T1/T2. In relation to the presence of positive regional lymph nodes, 17/20 patients after surgery remained N0 and 3/20 (15%) clinically Staged N0 were N positive. (Table 06)

Table 06. The comparison between clinical (cTNM) and pathological (pTNM) Stage  I of patients with gastric adenocarcinoma.

Table 07. The comparison of clinical (cTNM) and neoadjuvant (yTNM) staging in 38 patients of gastric adenocarcinoma.


This study describes the clinical, pathological, and neoadjuvant staging I in 63 patients with gastric adenocarcinoma. This is one of the first epidemiologic studies evaluating TN staging in the era of neoadjuvant treatment and its comparison to clinical and pathological stagings in a Latin American population. Our results showed reduction of tumor (T) and regional lymph nodes (N) staging on patients classified as T3/T4 and positive lymph nodes (N+) submitted to neoadjuvant treatment. However, there was no difference regarding the tumor and lymph nodes when comparing clinical and pathological staging. 
The MAGIC trial written by Cunningham, et al. (2006)6 was one of the first studies that identified improved long-term survival rates using preoperative chemotherapy for resectable gastric or gastroesophageal cancer, due to decreased tumor size and stage°. Although this study did not evaluate survival rates, reduction on tumor and lymph nodes scale for cases treated with neoadjuvant chemotherapy were observed, which could influence overall survival.

In the systematic review of Miao et al. (2018)11 they included 12 randomized clinical studies with neoadjuvant chemotherapy in 1,538 patients with gastric adenocarcinoma, it was observed increased global overall survival and progression free survival. Ychou et al. (2011)12 in France, compared treatments with and without neoadjuvant chemotherapy for gastric adenocarcinoma and concluded that patients who underwent neoadjuvant treatment had better overall 5-year survival rate than the ones that underwent only surgery. A study by Coccolini et al. (2018 3 about the treatments of gastric cancer, included neoadjuvant chemotherapy to convert unresectable tumors into resectable ones, which resulted on an increased overall survival 3.

Very similarly with the present study, Xu et al. (2014)4, observed lesser number of cases with positive lymph nodes for patients who underwent neoadjuvant chemotherapy. In 2016, a systematic review with 1,240 patients described positive results repardinp the effectiveness of neoadjuvant therapy in comparison of other treatments5. In this study, 34 tumors T3/T4 migrated to T1/T2, becoming resectables tumors after neoadjuvant chemotherapy, confirming the findings of Coccolini et al. 2018 3. Gastric cancer has been reported as more common in men above 60 years and twice more frequent on Caucasians 3. This profile was found on the present study, except for the ape, with an average of 58 years old, lower than the literature.

A systematic review done in Italy, 2017, by Patreli et al.7 with 61,468 patients, observed that patients with histological diffuse type had worse prognosis In a study done in Romania, where the tumors histological type was analyzed in 154 patients, the intestinal type was more frequent (49.1%). In the present study, the diffuse type was more frequent on patients with advanced cTNM (T3/T4) while early cTNM (T1/T2) in the intestinal type /7 18 One of the limitations of this study is the small number of patients at an early Stage I, which prevents stratification of groups for more detailed analysis.

In this study we evidence the epidemiological aspects and main T (tumor) and N (regional lymph-nodes) profiles of gastric adenocarcinoma from clinical, pathological, and neoadjuvant settings, which are the main indicators of prognosis for gastric cancer. It was possible to identify regression of both diffuse and intestinal types of tumor (T) and positive lymph nodes (N) on the group treated with neoadjuvant chemotherapy. Regarding patients with stage, I who underwent only surgery, without neoadjuvant therapy, there was no significant differences between clinical and pathological Stage I, which supports consistence between the three Stages settings on cases of gastric adenocarcinoma.

Competing Interest:
The authors declare that they have no competing interest

Funding Statement:
This study was under the Institutional Scientific Initiation Scholarship Program (Programa Institucional de Bolsas de Inicia$âo Cientifica PIBIC) funded by the National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Cientifico e Tecnologico - CNPq). The study was also funded by the FAPESP under the number 2014/26897-0.

Ethics approval
The Ethics Committee of A. C. Camargo Cancer Center have approved this study.

Acknowledgement Statement:
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