Hemorrhage during gastrectomy linked to increased cancer recurrence

1. Greater hemorrhaging in patients undergoing gastrectomy for gastric cancer correlated with higher incidence of cancer recurrence in the patient peritoneum.

2. The risk of peritoneal recurrence additionally correlated to depth of the tumor, and was higher in female patients.

Evidence Rating Level: 3 (Average)

Study Rundown: Nearly 11,000 gastric cancer patients died in the US last year, and newly diagnosed patients have less than a 30% chance of survival over 5 years. Recurrence of the cancer often occurs after primary surgical removal of the cancerous stomach tissue, with metastatic recurrence often widespread and difficult to manage. Several studies have suggested aspects of the primary gastric surgery, including the amount of bleeding, may affect the incidence of recurrence. This current study investigated a potential link between the volume of patient hemorrhage during gastrectomy, and the incidence of tumor recurrence.

The authors found that gastric cancer patients who experienced greater hemorrhaging during gastrectomy demonstrated an increased risk for recurrence of the cancer in the peritoneum, the membrane that lines the abdominal cavity. Whether this association is causative is questionable, as the increased peritoneal recurrence was also, and more strongly, associated with depth of the original tumor. Thus, it is possible that removing the larger tumor drives increased hemorrhaging as well as increased recurrence. While an in vitro check of tumor cell adhesion suggested that exposure to blood plasma increases the adhesion of the tumor cells, it remains unclear if plasma exposure alone drives tumor recurrence. Interestingly, blood transfusions during the surgery had no effect on the recurrence, suggesting factors other than plasma exposure are likely at play. Despite the clear need for further studies, this work does explore the interesting question – can we investigate and adjust our surgical technique to reduce the rate of cancer recurrence?

Click to read the study in the Journal of Surgical Oncology

Relevant Reading: Recurrence After Curative Resection of Early Gastric Cancer

In-Depth [retrospective cohort]: This study examined the incidence of cancer recurrence in 540 gastric cancer patients following macroscopically curative gastrectomy. Patient, surgery, and disease characteristics were collected via patient records or follow up appointments. Such characteristics included patient sex, amount of hemorrhaging during surgery, and primary tumor stage and depth. Tumor recurrence events were largely confirmed by biopsy, though in some cases through radiological images or clinical examination.

Predictive factors for increased risk of peritoneal recurrence included the female sex, deeper tumor depth, and larger amount of hemorrhaging during gastrectomy (> 326g hemorrhaged material). However, when multivariate analysis was used to examine the independent impact of hemorrhaging on peritoneal recurrence, no significant effect was found (p = 0.144), unless evaluated specifically for stage 4 tumors. In the case of these late stage tumors, the large hemorrhage patients developed recurrence more frequently (p = 0.041). Patients of the large hemorrhage group did not have an increased risk of cancer recurrence overall, or in other specific regions excluding the peritoneum. Patient sex and tumor depth remained independent predictors of cancer recurrence after multivariate analysis. Researchers performed an in vitro experiment in which they exposed mesothelial cells to blood plasma, and found that cells were more adhesive than when exposed to a control liquid (EDTA).

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Image: PD

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