Effectiveness of Neoadjuvant Chemotherapy with a Docetaxel, Cisplatin, and S-1 (DCS) Regimen for T4b Gastric Cancer

Effectiveness of Neoadjuvant Chemotherapy with a Docetaxel, Cisplatin, and S-1 (DCS) Regimen for T4b Gastric Cancer | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effectiveness of Neoadjuvant Chemotherapy with a Docetaxel, Cisplatin, and S-1 (DCS) Regimen for T4b Gastric Cancer Vo Duy Long, Dang Quang Thong, Tran Quang Dat, Doan Thuy Nguyen, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4985426/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Dec, 2024 Read the published version in World Journal of Surgical Oncology → Version 1 posted 21 You are reading this latest preprint version Abstract Background: No studies on neoadjuvant chemotherapy for gastric cancer (GC) with T4b stage were reported. This study aimed to assess the effectiveness of neoadjuvant chemotherapy using DCS regimen (docetaxel, cisplatin, and S-1) for GC with T4b stage Methods: Forty-three patients diagnosed GC with surgical or clinical T4b stage received three or four preoperative cycles of DCS therapy followed by gastrectomy and lymphadenectomy between Jan-2018 and Dec-2022. Short-tern outcomes including tumor response, completion of neoadjuvant chemotherapy, toxicity and adverse events, rate of treatment-related death, R0 resection, rate of complete adjuvant chemotherapy and short-term surgical results were investigated. The oncologic outcomes comprised 3-year OS and 3-year disease-free survival (DFS). Results: The completion rate of neoadjuvant chemotherapy was 88.4%, including 4 cycles of 51.2% and 3 cycles of 37.2%. The disease-control and clinical response rate were 88.4% and 58.1%, respectively. During preoperative chemotherapy, grade 3/4 neutropenia occurred in 20.9%, anemia in 13.9%, hyponatremia in 4.8%, and vomiting in 2.3%. Pathologic complete response was achieved in 8.0%. After surgery, no patient experienced severe complications (Clavien Dindo >= 3). The R0 resection rate was 72.0% and the rate of complete adjuvant chemotherapy was 83.3%. The 3-year OS and DFS rates were 49% and 38%, respectively. Conclusions: Neoadjuvant chemotherapy with DCS regimen demonstrated a high tolerance, high tumor response rate, high complete adjuvant chemotherapy rate and satisfactory 3-year survival outcomes. Three- or four-course of preoperative DCS regimen is a promising approach for GC with T4b stage. Gastric cancer Neoadjuvant chemotherapy T4b stage Clinical response rate DCS regimen Figures Figure 1 INTRODUCTION Gastric cancer (GC) poses a major public health challenge and ranks the most prevalent cancers in the world. For advanced cases, a multidisciplinary therapy is necessary for treatment. Gastrectomy and proper D2 lymphadenectomy remains a curative treatment for resectable tumors. Achieving complete surgical resection (R0) plays the most important factor for improving survival rates. In patients with T4b stage GC, curative surgery might not be achieved due to the direct invasion of tumor into the adjacent organs and/or major blood vessels. In previous studies, gastrectomy combined with multivisceral resection (MVR) was conducted to attain R0 surgery. However, MVR is associated with elevated rates of morbidity and mortality with the rate of severe complications of 5.0–33.3% [ 1 – 17 ]. The non-curative resection rate was reported as 20–47% [ 3 – 12 ] and the compliance of adjuvant therapy after MVR was low (25–59.5%) [ 4 , 6 , 7 , 9 , 11 , 12 ]. These factors resulted in the unsatisfactory 5-year overall survival (OS) rate of only 16–30% for those who underwent upfront gastrectomy [ 6 , 8 – 12 , 17 – 21 ]. Thus, the upfront radical surgery of GC with T4b is still challenging and may lead to a poor prognosis. For advanced GC, neoadjuvant chemotherapy has been suggested to reduce tumor invasiveness, improve the R0 resection rate, and mitigate the poor prognosis [ 22 – 26 ]. Neoadjuvant chemotherapy with 5-FU, leucovorin, oxaliplatin, docetaxel (FLOT) or epirubicin, cisplatin, 5-FU (ECF) or ebirubicin, cisplatin, capecitabine (ECX) regimens were recommended for advanced GCs in Western countries [ 27 – 31 ]. However, in Asian countries, the S-1 based regimens were favorable in several studies. Among that, DCS regimen was utilized for preoperative chemotherapy for GC with advanced stage or extended lymph node metastasis in several trials. This triplet regimen demonstrated high completion rate, clinical response rate, and promising oncologic outcomes [ 32 – 36 ]. Until now, no studies on neoadjuvant chemotherapy focusing on the T4b stage have been reported. Thus, investigations on neoadjuvant chemotherapy for GC with T4b is necessary. Therefore, we conducted this study to assess the effectiveness of neoadjuvant chemotherapy using DCS regimen (docetaxel, cisplatin, and S-1) for the treatment of GC with T4b stage in terms of safety, toxicity, response rate, surgical and oncological outcomes. PATIENTS AND METHODS Patients This retrospective study included 43 Vietnamese patients with clinical or surgical T4b GC between January 2018 and December 2022 at the Gastro-intestinal Surgical Department of the University Medical Center, a tertiary hospital in Ho Chi Minh City, Vietnam. The study was approved by the Institutional Review Board of the hospital. The eligibility criteria included: (i) confirmed histology of gastric adenocarcinoma, (ii) clinical or surgical staging at T4b stage, (iii) satisfactory hematological, liver, and renal functions, with specific parameters including a white blood cell count from 4,000 to 12,000/mm3, neutrophil count ≥ 2,000/mm3, hemoglobin > 10 g/dL, platelet count ≥ 100,000/mm3, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) ≤ 100 IU/L; total bilirubin ≤ 1.5 mg/dL; creatinine ≤ 1.2 mg/dL and creatinine clearance ≥ 60 mL/min, and (iv) an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1. Criteria for clinical T4b staging: abscence of normal fatty planes between the tumor and surrounding organs on an abdominal computed tomography scan, and reviewed by a multidisciplinary team (MDT), or identified intraoperative finding. The exclusion criteria comprised of (a) presence of distant organ metastasis (M1), except para aorta lymph node metastasis, (b) tumor invaded into the pancreatic head (right side of the gastroduodenal artery) or the hepatic hilum, (c) concurrent or history of previous other cancers, (d) prior chemotherapy treatment, (e) history of gastrectomy, (f) presence of central nervous system disorder, (g) active hepatitis B, and (h) pregnancy or breastfeeding. Neoadjuvant chemotherapy and response assessment Patients received 3 or 4 cycles of neoadjuvant chemotherapy. Each cycle included docetaxel (35 mg/m², intravenous) and cisplatin (35 mg/m², intravenous) on day 1 and 15, and S-1 (40 mg/m², oral, twice daily) from day 1 to 14, followed by a 2-week rest period. For one cycle, the total dosage was 70 mg/m² docetaxel, 70 mg/m² cisplatin, and 1120 mg/m² S-1 (dose intensity of S-1 of 280 mg/m²/week). If toxicity or adverse side effects occurred, the next cycle was delayed until recovery, with required criteria including: neutrophil count ≥ 1000/mm 3 , hemoglobin ≥ 10.0 g/dL, platelet count ≥ 50,000/mm 3 , AST and ALT ≤ 150 IU/L, total bilirubin ≤ 2 mg/dL, and creatinine ≤ 1.2 mg/dL. For patients who had gastric outlet obstruction, a stomach partitioning gastro-jejunostomy was performed, and chemotherapy was administered within 2–3 weeks later. The ECOG performance status was evaluated, and routine assessments including complete blood cell counts, liver and renal function tests, and urinalysis were conducted before each cycle to monitor toxicity and adverse events. Thoraco-abdominal computed tomography (CT) was performed at the end of the third and the fourth cycle to evaluate tumor response using the Response Evaluation Criteria in Solid Tumor (RECIST) 1.1 to assess the disease response [ 37 ]. The response categories were defined as follows: complete response (CR) indicated the complete disappearance of all target lesions; partial response (PR) indicated a ≥ 30% reduction in the sum of the diameters of all target lesions; progressive disease (PD) was identified by an increase in the sum of the diameters of all target lesions by ≥ 20%; and stable disease (SD) was characterized by insufficient shrinkage to qualify for PR or insufficient increase to qualify for PD. Patients with either CR or PR were considered to have a clinical response. The disease control rate included the rate of CR, PR, and SD. The Common Toxicity Criteria of the National Cancer Institute (NCI–CTC) 4.0 was used to report toxicities and adverse events [ 38 ]. Surgery after neoadjuvant chemotherapy We performed gastrectomy with lymphadenectomy according to the JGCA guidelines within 2–4 weeks after the last day of neoadjuvant chemotherapy administration [ 39 , 40 ]. Based on the primary tumor’s location, subtotal or total gastrectomy with lymphadenectomy was performed using laparoscopy or laparotomy. For patients with persistent PAN after neoadjuvant chemotherapy, 16a2/b1 PAN dissection was conducted. We carried out the D1 + lymphadenectomy in patients with several concomitant diseases. Intraoperative lavage cytology was routinely performed before and after gastrectomy. In cases of the invaded organs persisting after neoadjuvant chemotherapy, combined resection was conducted to achieve R0 resection. Additionally, any suspected margin of the invaded organs after gastrectomy was biopsied to assess residual tumor status. All surgical procedures were conducted by two experienced GC surgeons. Curative resection (R0) was defined as the complete removal of both macroscopic and microscopic disease. R1 resection was characterized by the macroscopic removal of the tumor, accompanied by microscopic evidence of residual tumor, indicated by either positive resection margin (including suspected margin of the invaded organs) or positive postoperative lavage cytology. Adjuvant treatment For patients who completed four cycles of neoadjuvant chemotherapy, S-1 was administered for one year after surgery. For patients who completed three cycles preoperatively, the fourth cycle of DCS was given postoperatively, followed by S-1 for 1 year. Follow-up The follow-up schedule was in accordance with the JGCA guidelines [ 39 , 40 ]. Patients were followed up every 3-month for the first two years, every 6-month for the next three years, and then annually. The follow-up visit included a physical examination, laboratory blood tests, and abdominal ultrasonography. Computed tomography was performed every six months for the first three years and then annually. Endoscopy was performed every year. If a patient exhibited suggestive symptoms or signs of recurrence or metastasis, CT and/or endoscopy were performed irrespective of the scheduled follow-up. Outcomes We investigated the short-tern outcomes including tumor response, completion of neoadjuvant chemotherapy, toxicity and adverse events, the rates of treatment-related death, R0 resection, the rate of complete adjuvant chemotherapy and short-term surgical results. The oncologic outcomes comprised 3-year OS and 3-year disease-free survival (DFS). Statistical analysis Continuous variables were summarized by mean ± standard deviation or median (25th ; 75th percentiles), and categorical variables were summarized by the number of patients and percentage. Baseline characteristics were summarized for all patients and by three distinct groups: surgery, refuse surgery, and PD. OS and DFS were summarized using Kaplan-Meier method and visualized by the Kaplan-Meier curves. Cox model was used to compare OS and DFS between groups. Results were reported by hazard ratio (HR), 95% confidence interval (CI), and p-value. The DFS was analyzed for patients with R0 resection only. All analyses were done using R statistical software version 4.1.3. Univariable analysis was performed using two-sample t-test for normally distributed numeric variables, the Wilcoxon rank-sum test for non-normally distributed numeric variables, and Fisher's exact test for categorical variables. Multivariable analysis was conducted using logistic regression models with a stepwise backward procedure to identify independent risk factors of overall survival rate. RESULTS Patient’s characteristics The clinico-pathological characteristics are presented in Table 1 . The mean age of the patients was 55.7 ± 12.6 years, with a male-to-female ratio of 2:1. Among the participants, 11 patients (25.6%) had bulky lymph nodes, and 8 patients (18.6%) had para aortic lymph nodes involvement. The mean neoadjuvant chemotherapy tumor size was 3.8 ± 2.3 cm. Five patients (11.6%) had gastric outlet obstruction and underwent partitioning gastro-jejunostomy before receiving chemotherapy. Fifteen patients (34.9%) with anemia at the time of admission received blood transfusions until reaching the hemoglobin threshold of 10 g/dL. Table 1 Patient characteristics All patients (N = 43) Surgery (N = 25) Refuse surgery (N = 13) PD (N = 5) Age (years) 55.7 ± 12.6 55.3 ± 13.1 57.7 ± 14.0 52.8 ± 5.6 Sex Male 29 (67.4) 18 (72.0) 9 (69.2) 2 (40.0) Female 14 (32.6) 7 (28.0) 4 (30.8) 3 (60.0) BMI (kg/m2) 20.8 ± 2.8 21.1 ± 2.8 20.7 ± 3.1 19.8 ± 2.4 Nutritional status Underweight (BMI 30) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) Hypertension 7 (16.3) 5 (20.0) 2 (15.4) 0 (0.0) Diabetes 5 (11.6) 3 (12.0) 2 (15.4) 0 (0.0) Cardiovascular disease 4 (9.3) 2 (8.0) 2 (15.4) 0 (0.0) Chronic hepatic disease 2 (4.7) 1 (4.0) 1 (7.7) 0 (0.0) Chronic lung disease 2 (4.7) 2 (8.0) 0 (0.0) 0 (0.0) Previous stroke 1 (2.3) 1 (4.0) 0 (0.0) 0 (0.0) Chronic renal disease 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) History of laparotomy or laparoscopic surgery 2 (4.7) 2 (8.0) 0 (0.0) 0 (0.0) CEA (U/L) 3.3 (1.7; 9.6) 3.3 (1.7; 8.7) 3.0 (1.7; 11.6) 3.5 (1.7; 5.0) Preoperative WBC (g/L) 8.5 ± 2.6 9.0 ± 2.4 8.3 ± 3.1 6.5 ± 1.3 Hemoglobin (g/dL) 11.6 ± 2.5 11.6 ± 2.8 11.6 ± 2.0 11.3 ± 1.8 Anemia 15 (34.9) 9 (36.0) 4 (30.8) 2 (40.0) Gastric outlet obstruction 5 (11.6) 2 (8.0) 2 (15.4) 1 (20.0) Pre-CT tumor size (cm) 3.8 ± 2.3 4.2 ± 2.6 3.2 ± 1.5 3.7 ± 1.7 Differentiation status Moderately differentiated 15 (34.9) 11 (44.0) 4 (30.8) 0 (0.0) Poorly differentiated 26 (60.5) 14 (56.0) 7 (53.8) 5 (100.0) Signet ring cell 2 (4.7) 0 (0.0) 2 (15.4) 0 (0.0) Para aorta lymph node 8 (18.6) 2 (8.0) 4 (30.8) 2 (40.0) Clinical N stage N1 5 (11.6) 4 (16.0) 0 (0.0) 1 (20.0) N2 17 (39.5) 8 (32.0) 8 (61.5) 1 (20.0) N3 10 (23.3) 3 (12.0) 5 (38.5) 2 (40.0) Bulky 11 (25.6) 10 (40.0) 0 (0.0) 1 (20.0) Number of CT cycles 1 1 (2.3) 1 (4.0) 0 (0.0) 0 (0.0) 2 4 (9.3) 3 (12.0) 1 (7.7) 0 (0.0) 3 16 (37.2) 9 (36.0) 5 (38.5) 2 (40.0) 4 22 (51.2) 12 (48.0) 7 (53.9) 3 (60.0) Response after 4 cycles CR 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) PR 25 (58.1) 18 (72.0) 7 (53.8) 0 (0.0) SD 13 (30.2) 7 (28.0) 6 (46.2) 0 (0.0) PD 5 (11.6) 0 (0.0) 0 (0.0) 5 (100.0) Length of follow-up (months) 19.0 (13.3; 27.9) 24.1 (16.8; 37.8) 16.1 (9.3; 20.5) 13.3 (8.1; 16.5) Summary statistics are mean ± sd, n (%), and median (25th; 75th percentiles) BMI: body mass index, CEA: carcinoembryonic antigen, WBC: white blood cell, CT: chemotherapy, CR: complete response, PR: partial response, SD: stable disease, PD: progress disease. Tumor response The total completion rate per protocol (3 or 4 cycles) was 88.4%, including 22 patients (51.2%) completed a course of 4 cycles and 16 patients (37.2%) underwent 3 cycles of neoadjuvant chemotherapy. The disease control rate was 88.4% (38 patients), including PR in 25 patients (58.1%) and SD in 13 patients (30.2%). There were no CR patients and 5 patients (11.6%) with PD. The clinical RR was 58.1% (all with PR). Twenty-five patients of those with PR or SD agreed to undergo gastrectomy and lymph node dissection, while the remaining 13 patients refused surgery. The patients who refused surgery continued with DCS regimen for enough 6 cycles and then received S-1 for 1 year. All 5 patients developed PD received second-line chemotherapy. (Table 1 ) Toxicity and adverse events Toxicity and adverse events are shown in Table 2 . We observed four toxicities and adverse events with grade 3–4, including neutropenia (8 patients [18.6%] with grade 3 and 1 patient [2.3%] with grade 4), anemia (5 patients [11.6%] with grade 3 and 1 patient [2.3%] with grade 4), hyponatremia (2 patients [4.8%] with grade 3), and vomiting (1 patient [2.3%] with grade 3). No treatment-related death was observed. Table 2 Treatment-related adverse event None Grade 1 Grade 2 Grade 3 Grade 4 General fatigue 32 (74.4) 9 (20.9) 2 (4.7) 0 (0.0) 0 (0.0) Vomitting 35 (81.4) 6 (14.0) 1 (2.3) 1 (2.3) 0 (0.0) Diarrhoea 35 (81.4) 7 (16.3) 1 (2.3) 0 (0.0) 0 (0.0) Anorexia 42 (97.7) 1 (2.3) 0 (0.0) 0 (0.0) 0 (0.0) Rash 43 (100.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) Pneumonitis 38 (90.5) 3 (7.1) 1 (2.4) 0 (0.0) 0 (0.0) Peripheral neuropathy 41 (95.3) 2 (4.7) 0 (0.0) 0 (0.0) 0 (0.0) Stomatitis 40 (93.0) 3 (7.0) 0 (0.0) 0 (0.0) 0 (0.0) Pigmentation 42 (97.7) 1 (2.3) 0 (0.0) 0 (0.0) 0 (0.0) Leukopenia 26 (60.5) 11 (25.6) 6 (14.0) 0 (0.0) 0 (0.0) Neutropenia 23 (53.5) 6 (14.0) 5 (11.6) 8 (18.6) 1 (2.3) Febrile neutropenia 42 (100.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) Anemia 16 (37.2) 13 (30.2) 8 (18.6) 5 (11.6) 1 (2.3) Thrombocytopenia 41 (95.3) 2 (4.7) 0 (0.0) 0 (0.0) 0 (0.0) Elevated bilirubin 38 (88.4) 5 (11.6) 0 (0.0) 0 (0.0) 0 (0.0) Elevated SGOT 40 (93.0) 3 (7.0) 0 (0.0) 0 (0.0) 0 (0.0) Elevated SGPT 42 (97.7) 1 (2.3) 0 (0.0) 0 (0.0) 0 (0.0) Decreased BUN 42 (97.7) 1 (2.3) 0 (0.0) 0 (0.0) 0 (0.0) Proteinuria 41 (95.3) 2 (4.7) 0 (0.0) 0 (0.0) 0 (0.0) Hypokalemia 39 (92.9) 3 (7.1) 0 (0.0) 0 (0.0) 0 (0.0) Hyponatremia 32 (76.2) 8 (19.0) 0 (0.0) 2 (4.8) 0 (0.0) Summary statistics is n (%) Operative characteristics and short-term outcomes Twenty-five patients underwent gastrectomy and lymphadenectomy. Among them, distal gastrectomy was performed in 10 patients (40.0%), and total gastrectomy in 15 patients (60.0%). Seven patients underwent combined resection, including left hepatic segmentectomy (1 patient), segmental transverse colectomy (2 patients), and distal pancreato-splenectomy (4 patients). D2 resection was conducted in 21 patients (84.0%), D1 + in 2 patients (8.0%), and D2 + PAND in 2 patients (8.0%). R0 resection was achieved in 72.0% (18/25). There were 4 patients (16.0%) with R1 and 3 patients (12.0%) with R2 resection. The median number of harvested lymph nodes was 16 (12; 25). The overall complication rate was 24.0%, however, no patient occurred severe complications (Clavien Dindo > = 3). The rate of complete adjuvant chemotherapy was 83.3%. (Table 3 ) Table 3 Operative characteristics N Surgery (N = 25) Operation type 25 Laparoscopy 13 (52.0) Open 12 (48.0) Operative method 25 Distal gastrectomy 10 (40.0) Total gastrectomy 15 (60.0) Borrmann 25 1 2 (8.0) 2 11 (44.0) 3 11 (44.0) 5 1 (4.0) Surgical tumor size (cm) 25 5 (4; 6) Operating time (mins) 25 215 (180; 250) Blood loss (ml) 25 100 (50; 150) Combined surgery 25 7 (28.0) Combined surgery specification 7 Left hepatic segmentectomy 1 (14.3) Segmental transverse colectomy 2 (28.6) Distal pancreato-splenectomy 4 (57.1) Extent of lymph node dissection 25 D1+ 2 (8.0) D2 21 (84.0) D2 + PAND 2 (8.0) Number of resected lymph nodes 25 16 (12; 25) Pathological T stage 25 T0 2 (8.0) T1 0 (0.0) T2 0 (0.0) T3 5 (20.0) T4a 14 (56.0) T4b 4 (16.0) Pathological N stage 25 N0 6 (24.0) N1 4 (16.0) N2 11 (44.0) N3a 4 (16.0) N3b 0 (0.0) Curability 25 R0 18 (72.0) R1 4 (16.0) R2 3 (12.0) Adjuvant chemotherapy 24 No 2 (8.3) Not complete 2 (8.3) Complete 20 (83.3) Postoperative hospital stay (days) 25 8 (7; 10) Time to flatus (days) 25 3 (2; 4) Time to liquid diet (days) 25 3 (2; 4) Anastomotic leakage 25 0 (0.0) Anastomotic stricture 25 0 (0.0) Duodenal stump leakage 25 0 (0.0) Pancreatic fistula 25 1 (4.0) Paralytic ileus 25 1 (4.0) Bleeding 25 0 (0.0) Intra-abdominal abscess 25 0 (0.0) Wound infection 25 0 (0.0) Early reoperation 25 0 (0.0) Cardiovascular complications 25 0 (0.0) Pneumonitis 25 3 (12.0) Urinary retention 25 1 (4.0) Clavien-Dindo classification 25 1 3 (12.0) 2 3 (12.0) >= 3 0 (0.0) Summary statistics are n (%), mean ± sd, and median (25th; 75th percentiles) PAND: para aortic lymph node dissection Pathologic complete response was achieved in 2 patients (8.0%). Long-term survival outcomes The median (25th ; 75th percentiles) length of follow-up was 19.0 (13.3; 27.9) months in the total study population, and 24.1 (16.8; 37.8) months in the surgery group. There were 27 deaths in the total population and 12 deaths in the surgery group. The 1-, 2-, and 3-year OS rates (95% CI) of the surgery group were 92% (82;100%), 65% (48;88%), and 49% (32;76%), respectively. The 1-, 2-, and 3-year OS rates (95% CI) of the refuse-surgery group were 76% (56;100), 8.5% (1.3;55), and 0%, respectively. (Fig. 1 ) The 1-, 2-, and 3-year DFS rates (95% CI) of the R0 group were 72 (54; 96), 48 (29; 79), and 38 (19, 75), respectively. For surgery group, the results from the univariable analyses showed that pathological lymph node stage, and incomplete adjuvant chemotherapy were identified to significantly reduce the overall survival. However, in the multivariable analyses, no independent risk factors were found to reduce the overall survival. (Table 4 ) Table 4 Univariable and multivariable analysis of factors associated with OS (surgery group) Univariable model Multivariable model Characteristic N HR 95% CI p-value HR 95% CI p-value Age (years) 25 1.02 0.97, 1.07 0.393 Sex 25 Male — — — — Female 2.28 0.72, 7.26 0.163 Pre- CT tumor size (cm) 25 0.93 0.69, 1.24 0.607 Borrmann 25 1.05 0.53, 2.10 0.880 Para aorta lymph node 25 3.03 0.63, 14.7 0.168 Differentiation status 25 Moderately differentiated — — — — Poorly differentiated 2.00 0.60, 6.70 0.260 Signet ring cell Operation type 25 Laparoscopy — — — — Open 0.86 0.28, 2.70 0.802 Operative method 25 Distal gastrectomy — — — — Total gastrectomy 2.41 0.71, 8.16 0.159 Response after 4 cycles 25 PR — — — — SD 0.40 0.09, 1.84 0.240 Pathological T stage 25 pT0-T3 — — — — pT4a 1.25 0.31, 5.00 0.757 pT4b 2.35 0.46, 11.9 0.304 Pathological N stage 25 pN0 — — — — pN1 7.81 1.14, 53.6 0.037 11.2 0.90, 139 0.060 pN2 2.06 0.41, 10.2 0.377 3.17 0.37, 27.3 0.293 pN3 1.84 0.16, 20.9 0.623 3.67 0.22, 61.2 0.365 Curability 25 R0 — — — — R1/2 0.69 0.19, 2.58 0.584 Combined surgery 25 0.88 0.24, 3.29 0.855 Adjuvant chemotherapy 24 Complete — — — — No/incomplete 5.23 1.22, 22.4 0.026 3.51 0.76, 16.3 0.109 Grade 3–4 adverse event 25 No — — — — Yes 1.96 0.58, 6.61 0.278 HR: hazard ratio, CI: confidence interval, CT: chemotherapy, PR: partial response, SD: stable disease Recurrence pattern after surgery Thirteen patients (52.0%) of the surgery group occurred recurrence and or metatstasis, including locaregional recurrence (1 patients), hematogenous (1 patients), peritoneum (2 patients), distant lymph node (1 patients), and mixed type (8 patients). DISCUSSION Patients of GC with T4b stage, gastrectomy and additional combined resection may be the only way for a potential cure. However, radical resection for cT4b gastric cancer may increase potential postoperative complications and carries a high risk of R1/R2 resection, especially when pancreatic head or liver are involved. Moreover, GC at the T4b stage often presents with high lymph nodes metastasis and peritoneal spread, which contribute to poorly survival outcomes [ 6 , 9 , 11 , 12 , 17 , 20 , 21 ]. Therefore, multivisceral resection for T4b gastric cancer remains controversial. This disorder should be treated as a separate group to achieve better survival outcomes. In our study, we expected to improve long-term survival and minimize the toxicity and adverse events of patients with T4b GC by applying neoadjuvant chemotherapy with DCS regimen, followed by gastrectomy and lymphadenectomy. The findings demonstrated much better efficacy than initially anticipated, with high compliance rate (88.4%), R0 resection rate (72.0%), low toxicities and adverse events, and satisfactory survival (3-year OS of 49%). These results enhanced the use of neoadjuvant chemotherapy with DCS regimen followed by gastrectomy and lymphadenectomy in this population, which has not been reported before. Besides the regimen for neoadjuvant chemotherapy, the dosage is also a critical factor in increasing the response rate and reducing toxicity. In Japan, a 2–3 cycle DCS (docetaxel, cisplatin and S-1) or CS (cisplatin and S-1) regimen was utilized for preoperative chemotherapy for GC with advanced stage or extended lymph node metastasis. However, there were a relatively high incidence of grade 3 or grade 4 toxicity and adverse events, particularly leukopenia (18.9–27.5%), neutropenia (19.0–55.0%), diarrhea (7.5–10%) [ 32 – 36 ]. A higher dose of docetaxel and cisplatin was supposed to be related to a higher incidence of grade 3–4 hematological toxicity [ 41 – 43 ]. In our study, the total dose of docetaxel (70 mg/m 2 /cycle) and cisplatin (70mg/m 2 /cycle), which was higher than in other studies, was adjusted by dividing it into biweekly schedules to reduce toxicity adverse effects. The dose intensity of docetaxel (17.5 mg/m 2 /week), cisplatin (17.5 mg/m 2 /week), and S-1 (280 mg/m 2 /week) were relatively higher in other trials. However, most of the toxicity and adverse events were in grade 1 or 2, while grade 3 or 4 of neutropenia and anemia were 20.9%, and 13.9%, respectively. These results were remarkably lower than reported in the other studies. Thus, a high completion and tolerance rate was obtained in our study population with this modified schedule. Regarding postoperative complications of gastrectomy and radical lymphadenectomy after neoadjuvant chemotherapy, the overall complication rate in our study was similar to several prior studies [ 32 , 33 , 43 – 46 ]. However, no patient experienced severe complications (ClavienDindo > = 3) in this study. Performing a radical resection for cT4b gastric cancer without neoadjuvant chemotherapy may increase the complexity of the operation and pose potential postoperative complications in certain cases, particularly when the pancreas and liver are involved. Some authors hypothesized that extensive resection was linked to a higher incidence of overall severe complications and mortality [ 14 , 20 ]. Conversely, recent studies support the notion that there is no disparity in postoperative complications between multivisceral resection and gastrectomy alone [ 6 , 7 , 10 , 11 ]. In our study, seven patients underwent combined resection, 21 patients underwent D2 resection, 2 patients underwent D1 + resection, and 2 patients underwent D2 + PAND. We didn't have any cases of severe complications such as anastomotic leak, bleeding, or severe complications after surgery. The feasibility and safety of extended gastrectomy were previously advocated, and our results are relatively better to those without neoadjuvant chemotherapy reported in the literature [ 2 , 5 , 7 , 8 , 10 , 12 , 13 , 15 – 17 ]. The adjuvant chemotherapy approach is required to improve the curability and survival outcome for T4b GC. Although MVR was considered safe and feasible with high rate of R0 resection for T4b gastric cancer, several previous studies demonstrated that initiation of adjuvant chemotherapy might be prolonged or even prohibited due to patient derailing after a large MVR. The rate of adjuvant chemotherapy was low (41–75%), resulting in unsatisfactory survival outcomes with 3-year OS of 10.8–39.0% [ 4 , 6 , 7 , 9 , 11 , 12 ]. In this manner, our study was among the limited data demonstrating the efficacy of neoadjuvant chemotherapy for T4b GC, with high rate of complete adjuvant chemotherapy (83.3%), low toxicities and morbidities, and satisfactory 3-year OS (49%) and DFS (38%). These findings were superior to those of previous studies, in which MVR surgery was performed without neoadjuvant chemotherapy [ 1 – 21 ]. Based on these results, we suggest applying neoadjuvant chemotherapy with DCS regimen over upfront surgery and adjuvant chemotherapy for T4b GC. Analyzed by univariate regression, our findings indicated that pathological lymph node stage and incomplete adjuvant chemotherapy significantly reduced the overall survival. However, due to the small sample size, the multivariable analyses did not reveal any independent risk factors. Several previous studies have identified the incompleteness of resection, lymph node metastasis, and the number of resected organs as independent prognostic factors for T4b GC. Among these, the most powerful prognostic factor was the completeness of resection, which has been confirmed by almost all the published studies [ 3 , 5 , 7 – 11 , 19 – 21 ]. This study had some limitations. Firstly, although the findings were potential, it was still a single-arm retrospective study at a single institution. Thus, controlled trials are required to propose a stronger recommendation. Secondly, the 5-year survival outcomes could not be evaluated in this study. We expected to report these outcomes in further study after a sufficient length of follow-up. Thirdly, the number of patients included in this study was relatively small when divided into separate groups, and further evaluations are required in larger populations. In conclusion, neoadjuvant chemotherapy with DCS regimen followed by gastrectomy and lymphadenectomy demonstrated a high tolerance, high tumor response rate, sufficient R0 resection rate, high complete adjuvant chemotherapy rate and satisfactory 3-year survival outcomes for GC with T4b. Preoperative DCS regimen with 3–4 cycles was a promising approach for GC with T4b stage. Declarations Acknowledgements Conflict of interest Drs. Vo Duy Long, Dang Quang Thong, Tran Quang Dat, Doan Thuy Nguyen, Tran Duy Phuoc, Nguyen Viet Hai, Nguyen Lam Vuong, Lam Quoc Trung and Nguyen Hoang Bac disclose any potential or actual personal, political or financial conflict of interest in the material, information or techniques described in the paper. Funding This research received no external funding. Ethical approval The study was conducted according to the guidelines of the Declaration of Helsinki and approved by Institutional Review Board, University Medical Center Ho Chi Minh city. Approval to perform research on human subjects in this study was provided by the Institutional Review Board, University Medical Center Ho Chi Minh city (registration number: 37/HDDD-DHYD) Data Availability Statement The data presented in this study are available on request from the corresponding author. References Wang GC, et al. Surgical outcomes and survival for T4 gastric cancer extending to the transverse colon. Ann Transl Med 2020;8:947. Ozer I, et al. Surgical outcomes and survival after multiorgan resection for locally advanced gastric cancer. Am J Surg 2009;198:25-30. Mita K, et al. Surgical outcomes and survival after extended multiorgan resection for T4 gastric cancer. Am J Surg 2012;203:107-11. Zhang X, et al. Short-term safety and Long-term efficacy of multivisceral resection in pT4b gastric cancer patients without distant metastasis: a 20-year experience in China National Cancer Center. J Cancer 2022;13:3113-20. Mita K, et al. Prognostic Factors Affecting Survival After Multivisceral Resection in Patients with Clinical T4b Gastric Cancer. J Gastrointest Surg 2017;21:1993-9. Sahakyan M, et al. Extended Gastrectomy for T4b Gastric Adenocarcinoma: Single-Surgeon Experience. J Gastrointest Cancer 2020;51:135-43. Jin P, et al. Retrospective analysis of surgically treated pT4b gastric cancer with pancreatic head invasion. World J Clin Cases 2021;9:8718-28. Carboni F, et al. Extended multiorgan resection for T4 gastric carcinoma: 25-year experience. J Surg Oncol 2005;90:95-100. Aversa JG, et al. Multivisceral Resection for Locally Advanced Gastric Cancer. J Gastrointest Surg 2021;25:609-22. Pacelli F, et al. Multivisceral resection for locally advanced gastric cancer: an Italian multicenter observational study. JAMA Surg 2013;148:353-60. Yang Y, et al. Multivisceral resection for locally advanced gastric cancer: A retrospective study. Am J Surg 2021;221:1011-7. Tran TB, et al. Multivisceral Resection for Gastric Cancer: Results from the US Gastric Cancer Collaborative. Ann Surg Oncol 2015;22 Suppl 3:S840-7. Lee CM, et al. How Does Combined Resection Affect the Clinical Outcomes After Laparoscopic Surgery for Serosa-Positive Gastric Cancer?: A Retrospective Cohort Study to Investigate the Short-Term Outcomes of Laparoscopic Combined Resection in Patients With T4b Gastric Cancer. Front Oncol 2019;9:1564. Brar SS, et al. Multivisceral resection for gastric cancer: a systematic review. Gastric Cancer 2012;15 Suppl 1:S100-7. Dias AR, et al. Prediction scores for complication and recurrence after multivisceral resection in gastric cancer. Eur J Surg Oncol 2020;46:1097-102. Favacho BC, et al. T4b gastric carcinoma: 12 years of experience at an University Hospital. Arq Bras Cir Dig 2013;26:268-73. Vladov N, et al. Аre Multivisceral Resections for Gastric Cancer Acceptable: Experience from a High Volume Center and Extended Literature Review? Surg J (N Y) 2023;9:e28-e35. Min JS, et al. Prognosis of curatively resected pT4b gastric cancer with respect to invaded organ type. Ann Surg Oncol 2012;19:494-501. Schizas D, et al. Multivisceral Resection for Locally Advanced Gastric Cancer: A Systematic Review and Evidence Quality Assessment. J Clin Med 2023;12. Kunisaki C, et al. Surgical outcomes in patients with T4 gastric carcinoma. J Am Coll Surg 2006;202:223-30. Kim DY, et al. T4 gastric carcinoma: the benefit of non-curative resection. ANZ J Surg 2006;76:453-7. Hayashi T, et al. Primary results of a randomized two-by-two factorial phase II trial comparing neoadjuvant chemotherapy with two and four courses of cisplatin/S-1 and docetaxel/cisplatin/S-1 as neoadjuvant chemotherapy for advanced gastric cancer. Ann Gastroenterol Surg 2020;4:540-8. Reddavid R, et al. Neoadjuvant chemotherapy for gastric cancer. Is it a must or a fake? World J Gastroenterol 2018;24:274-89. Kodera Y. Neoadjuvant chemotherapy for gastric adenocarcinoma in Japan. Surg Today 2017;47:899-907. Irino T, et al. Essential updates 2019/2020: Perioperative and surgical management of gastric cancer. Ann Gastroenterol Surg 2021;5:162-72. Tokunaga M, et al. Neoadjuvant chemotherapy for locally advanced gastric cancer in Japan: Consensus meeting at the 77th general meeting of the Japanese Society of Gastroenterological Surgery. Ann Gastroenterol Surg 2023;7:856-62. Cunningham D, et al. Capecitabine and oxaliplatin for advanced esophagogastric cancer. N Engl J Med 2008;358:36-46. Al-Batran SE, et al. Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel versus fluorouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric or gastro-oesophageal junction adenocarcinoma (FLOT4): a randomised, phase 2/3 trial. Lancet 2019;393:1948-57. Al-Batran SE, et al. Biweekly fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT) for patients with metastatic adenocarcinoma of the stomach or esophagogastric junction: a phase II trial of the Arbeitsgemeinschaft Internistische Onkologie. Ann Oncol 2008;19:1882-7. Smyth EC, et al. Gastric cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2016;27:v38-v49. Cunningham D, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med 2006;355:11-20. Tsuburaya A, et al. Neoadjuvant chemotherapy with S-1 and cisplatin followed by D2 gastrectomy with para-aortic lymph node dissection for gastric cancer with extensive lymph node metastasis. Br J Surg 2014;101:653-60. Ito S, et al. A phase II study of preoperative chemotherapy with docetaxel, cisplatin, and S-1 followed by gastrectomy with D2 plus para-aortic lymph node dissection for gastric cancer with extensive lymph node metastasis: JCOG1002. Gastric Cancer 2017;20:322-31. Kurokawa Y, et al. Short-term outcomes of preoperative chemotherapy with docetaxel, oxaliplatin, and S-1 for gastric cancer with extensive lymph node metastasis (JCOG1704). Gastric Cancer 2024. Sato Y, et al. A Phase II study of preoperative chemotherapy with docetaxel, oxaliplatin and S-1 in gastric cancer with extensive lymph node metastasis (JCOG1704). Future Oncol 2020;16:31-8. Tsuchida K, et al. Short-term results of a phase II study of preoperative docetaxel/cisplatin/S-1 therapy for locally advanced gastric cancer. Jpn J Clin Oncol 2021;51:371-8. Therasse P, et al. New guidelines to evaluate the response to treatment in solid tumors. European Organization for Research and Treatment of Cancer, National Cancer Institute of the United States, National Cancer Institute of Canada. J Natl Cancer Inst 2000;92:205-16. Trotti A, et al. CTCAE v3.0: development of a comprehensive grading system for the adverse effects of cancer treatment. Semin Radiat Oncol 2003;13:176-81. Japanese gastric cancer treatment guidelines 2018 (5th edition). Gastric Cancer 2021;24:1-21. Japanese Gastric Cancer Treatment Guidelines 2021 (6th edition). Gastric Cancer 2023;26:1-25. Holleran WM and DeGregorio MW. Evolution of high-dose cisplatin. Invest New Drugs 1988;6:135-42. Harvey V, et al. Phase III trial comparing three doses of docetaxel for second-line treatment of advanced breast cancer. J Clin Oncol 2006;24:4963-70. Esposito M, et al. Protective effect on cisplatin hematotoxicity by procaine hydrochloride. Cancer Lett 1992;64:55-60. Khaled I, et al. Oncological outcomes of laparoscopic versus open gastrectomy after neoadjuvant chemotherapy for locally advanced gastric cancer: a retrospective multicenter study. World J Surg Oncol 2021;19:206. Téoule P, et al. Impact of Neoadjuvant Chemotherapy on Postoperative Morbidity after Gastrectomy for Gastric Cancer. Dig Surg 2015;32:229-37. Umeda S, et al. Short-term outcomes of gastrectomy after neoadjuvant chemotherapy for clinical stage III gastric cancer: propensity score-matched analysis of a multi-institutional database. Surg Today 2021;51:821-8. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4985426","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":350380543,"identity":"b7c478b0-802e-413c-a7c5-cfbbe20c3acc","order_by":0,"name":"Vo Duy Long","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwElEQVRIiWNgGAWjYBACPgjFLAeh2YjQAlXDbEy6lsQG4rWw9x5+wdhmnb7h2uEHDB/KDjMY3G4goIXnXJoFY1t67obbaQaMM84Btdw5QECLRI6ZAcOZw0AtOQzMvG2HGSRnJBCnJd0ApOUvkVqMHzBUHE4Aa2EEauGXIKSF54wZQ0JFuuFMoF8O9pxL5yGohZ+9x/jDBwNreb7byQ8f/CizlmMjpAXsNpiaA0DMQ1A9EDB/IEbVKBgFo2AUjGAAAHKSPJsgSI8jAAAAAElFTkSuQmCC","orcid":"","institution":"University Medical Center at Ho Chi Minh City","correspondingAuthor":true,"prefix":"","firstName":"Vo","middleName":"Duy","lastName":"Long","suffix":""},{"id":350380544,"identity":"8baf1889-3ecf-4cca-bdab-0d8284a40c03","order_by":1,"name":"Dang Quang Thong","email":"","orcid":"","institution":"University Medical Center at Ho Chi Minh City","correspondingAuthor":false,"prefix":"","firstName":"Dang","middleName":"Quang","lastName":"Thong","suffix":""},{"id":350380546,"identity":"b6e156af-5d5c-416e-98bc-dc9fee4261c7","order_by":2,"name":"Tran Quang 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City","correspondingAuthor":false,"prefix":"","firstName":"Nguyen","middleName":"Viet","lastName":"Hai","suffix":""},{"id":350380553,"identity":"31319b5d-4fbb-4f27-8c28-7b553453943a","order_by":6,"name":"Nguyen Lam Vuong","email":"","orcid":"","institution":"University of Medicine and Pharmacy at Ho Chi Minh City","correspondingAuthor":false,"prefix":"","firstName":"Nguyen","middleName":"Lam","lastName":"Vuong","suffix":""},{"id":350380556,"identity":"2696f38f-6399-4d6f-9b66-05678249f6a6","order_by":7,"name":"Lam Quoc Trung","email":"","orcid":"","institution":"University Medical Center at Ho Chi Minh City","correspondingAuthor":false,"prefix":"","firstName":"Lam","middleName":"Quoc","lastName":"Trung","suffix":""},{"id":350380557,"identity":"b0ea63c8-719d-4efc-8821-a2af7d35385d","order_by":8,"name":"Nguyen Hoang Bac","email":"","orcid":"","institution":"University Medical Center at Ho Chi Minh City","correspondingAuthor":false,"prefix":"","firstName":"Nguyen","middleName":"Hoang","lastName":"Bac","suffix":""}],"badges":[],"createdAt":"2024-08-27 14:54:54","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4985426/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4985426/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12957-024-03620-1","type":"published","date":"2024-12-20T15:58:31+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":66887493,"identity":"bac5e5df-0f73-40fe-b22e-d5c64305d881","added_by":"auto","created_at":"2024-10-17 13:58:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":215534,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier curves for overall survival\u003c/p\u003e\n\u003cp\u003ePD: Progress Disease\u003c/p\u003e","description":"","filename":"Figure1KaplanMeierforsurvival.png","url":"https://assets-eu.researchsquare.com/files/rs-4985426/v1/1f839e2d7f38c07e855cf5c0.png"},{"id":72201985,"identity":"8bc8e0f3-2e89-49cd-b6de-f9cdc6f00686","added_by":"auto","created_at":"2024-12-23 16:13:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1214033,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4985426/v1/0a11da0b-7d66-42cd-bb13-7aa54223e34f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effectiveness of Neoadjuvant Chemotherapy with a Docetaxel, Cisplatin, and S-1 (DCS) Regimen for T4b Gastric Cancer","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eGastric cancer (GC) poses a major public health challenge and ranks the most prevalent cancers in the world. For advanced cases, a multidisciplinary therapy is necessary for treatment. Gastrectomy and proper D2 lymphadenectomy remains a curative treatment for resectable tumors. Achieving complete surgical resection (R0) plays the most important factor for improving survival rates. In patients with T4b stage GC, curative surgery might not be achieved due to the direct invasion of tumor into the adjacent organs and/or major blood vessels. In previous studies, gastrectomy combined with multivisceral resection (MVR) was conducted to attain R0 surgery. However, MVR is associated with elevated rates of morbidity and mortality with the rate of severe complications of 5.0\u0026ndash;33.3% [\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The non-curative resection rate was reported as 20\u0026ndash;47% [\u003cspan additionalcitationids=\"CR4 CR5 CR6 CR7 CR8 CR9 CR10 CR11\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and the compliance of adjuvant therapy after MVR was low (25\u0026ndash;59.5%) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. These factors resulted in the unsatisfactory 5-year overall survival (OS) rate of only 16\u0026ndash;30% for those who underwent upfront gastrectomy [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR9 CR10 CR11\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan additionalcitationids=\"CR18 CR19 CR20\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Thus, the upfront radical surgery of GC with T4b is still challenging and may lead to a poor prognosis.\u003c/p\u003e \u003cp\u003eFor advanced GC, neoadjuvant chemotherapy has been suggested to reduce tumor invasiveness, improve the R0 resection rate, and mitigate the poor prognosis [\u003cspan additionalcitationids=\"CR23 CR24 CR25\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Neoadjuvant chemotherapy with 5-FU, leucovorin, oxaliplatin, docetaxel (FLOT) or epirubicin, cisplatin, 5-FU (ECF) or ebirubicin, cisplatin, capecitabine (ECX) regimens were recommended for advanced GCs in Western countries [\u003cspan additionalcitationids=\"CR28 CR29 CR30\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. However, in Asian countries, the S-1 based regimens were favorable in several studies. Among that, DCS regimen was utilized for preoperative chemotherapy for GC with advanced stage or extended lymph node metastasis in several trials. This triplet regimen demonstrated high completion rate, clinical response rate, and promising oncologic outcomes [\u003cspan additionalcitationids=\"CR33 CR34 CR35\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUntil now, no studies on neoadjuvant chemotherapy focusing on the T4b stage have been reported. Thus, investigations on neoadjuvant chemotherapy for GC with T4b is necessary.\u003c/p\u003e \u003cp\u003eTherefore, we conducted this study to assess the effectiveness of neoadjuvant chemotherapy using DCS regimen (docetaxel, cisplatin, and S-1) for the treatment of GC with T4b stage in terms of safety, toxicity, response rate, surgical and oncological outcomes.\u003c/p\u003e"},{"header":"PATIENTS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eThis retrospective study included 43 Vietnamese patients with clinical or surgical T4b GC between January 2018 and December 2022 at the Gastro-intestinal Surgical Department of the University Medical Center, a tertiary hospital in Ho Chi Minh City, Vietnam. The study was approved by the Institutional Review Board of the hospital.\u003c/p\u003e \u003cp\u003eThe eligibility criteria included: (i) confirmed histology of gastric adenocarcinoma, (ii) clinical or surgical staging at T4b stage, (iii) satisfactory hematological, liver, and renal functions, with specific parameters including a white blood cell count from 4,000 to 12,000/mm3, neutrophil count\u0026thinsp;\u0026ge;\u0026thinsp;2,000/mm3, hemoglobin\u0026thinsp;\u0026gt;\u0026thinsp;10 g/dL, platelet count\u0026thinsp;\u0026ge;\u0026thinsp;100,000/mm3, aspartate aminotransferase (AST) and alanine aminotransferase (ALT)\u0026thinsp;\u0026le;\u0026thinsp;100 IU/L; total bilirubin\u0026thinsp;\u0026le;\u0026thinsp;1.5 mg/dL; creatinine\u0026thinsp;\u0026le;\u0026thinsp;1.2 mg/dL and creatinine clearance\u0026thinsp;\u0026ge;\u0026thinsp;60 mL/min, and (iv) an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1.\u003c/p\u003e \u003cp\u003eCriteria for clinical T4b staging: abscence of normal fatty planes between the tumor and surrounding organs on an abdominal computed tomography scan, and reviewed by a multidisciplinary team (MDT), or identified intraoperative finding.\u003c/p\u003e \u003cp\u003eThe exclusion criteria comprised of (a) presence of distant organ metastasis (M1), except para aorta lymph node metastasis, (b) tumor invaded into the pancreatic head (right side of the gastroduodenal artery) or the hepatic hilum, (c) concurrent or history of previous other cancers, (d) prior chemotherapy treatment, (e) history of gastrectomy, (f) presence of central nervous system disorder, (g) active hepatitis B, and (h) pregnancy or breastfeeding.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eNeoadjuvant chemotherapy and response assessment\u003c/h2\u003e \u003cp\u003ePatients received 3 or 4 cycles of neoadjuvant chemotherapy. Each cycle included docetaxel (35 mg/m\u0026sup2;, intravenous) and cisplatin (35 mg/m\u0026sup2;, intravenous) on day 1 and 15, and S-1 (40 mg/m\u0026sup2;, oral, twice daily) from day 1 to 14, followed by a 2-week rest period. For one cycle, the total dosage was 70 mg/m\u0026sup2; docetaxel, 70 mg/m\u0026sup2; cisplatin, and 1120 mg/m\u0026sup2; S-1 (dose intensity of S-1 of 280 mg/m\u0026sup2;/week).\u003c/p\u003e \u003cp\u003eIf toxicity or adverse side effects occurred, the next cycle was delayed until recovery, with required criteria including: neutrophil count\u0026thinsp;\u0026ge;\u0026thinsp;1000/mm\u003csup\u003e3\u003c/sup\u003e, hemoglobin\u0026thinsp;\u0026ge;\u0026thinsp;10.0 g/dL, platelet count\u0026thinsp;\u0026ge;\u0026thinsp;50,000/mm\u003csup\u003e3\u003c/sup\u003e, AST and ALT\u0026thinsp;\u0026le;\u0026thinsp;150 IU/L, total bilirubin\u0026thinsp;\u0026le;\u0026thinsp;2 mg/dL, and creatinine\u0026thinsp;\u0026le;\u0026thinsp;1.2 mg/dL.\u003c/p\u003e \u003cp\u003eFor patients who had gastric outlet obstruction, a stomach partitioning gastro-jejunostomy was performed, and chemotherapy was administered within 2\u0026ndash;3 weeks later.\u003c/p\u003e \u003cp\u003eThe ECOG performance status was evaluated, and routine assessments including complete blood cell counts, liver and renal function tests, and urinalysis were conducted before each cycle to monitor toxicity and adverse events. Thoraco-abdominal computed tomography (CT) was performed at the end of the third and the fourth cycle to evaluate tumor response using the Response Evaluation Criteria in Solid Tumor (RECIST) 1.1 to assess the disease response [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The response categories were defined as follows: complete response (CR) indicated the complete disappearance of all target lesions; partial response (PR) indicated a\u0026thinsp;\u0026ge;\u0026thinsp;30% reduction in the sum of the diameters of all target lesions; progressive disease (PD) was identified by an increase in the sum of the diameters of all target lesions by \u0026ge;\u0026thinsp;20%; and stable disease (SD) was characterized by insufficient shrinkage to qualify for PR or insufficient increase to qualify for PD. Patients with either CR or PR were considered to have a clinical response. The disease control rate included the rate of CR, PR, and SD.\u003c/p\u003e \u003cp\u003eThe Common Toxicity Criteria of the National Cancer Institute (NCI\u0026ndash;CTC) 4.0 was used to report toxicities and adverse events [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSurgery after neoadjuvant chemotherapy\u003c/h2\u003e \u003cp\u003eWe performed gastrectomy with lymphadenectomy according to the JGCA guidelines within 2\u0026ndash;4 weeks after the last day of neoadjuvant chemotherapy administration [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Based on the primary tumor\u0026rsquo;s location, subtotal or total gastrectomy with lymphadenectomy was performed using laparoscopy or laparotomy. For patients with persistent PAN after neoadjuvant chemotherapy, 16a2/b1 PAN dissection was conducted. We carried out the D1\u0026thinsp;+\u0026thinsp;lymphadenectomy in patients with several concomitant diseases. Intraoperative lavage cytology was routinely performed before and after gastrectomy. In cases of the invaded organs persisting after neoadjuvant chemotherapy, combined resection was conducted to achieve R0 resection. Additionally, any suspected margin of the invaded organs after gastrectomy was biopsied to assess residual tumor status. All surgical procedures were conducted by two experienced GC surgeons.\u003c/p\u003e \u003cp\u003eCurative resection (R0) was defined as the complete removal of both macroscopic and microscopic disease. R1 resection was characterized by the macroscopic removal of the tumor, accompanied by microscopic evidence of residual tumor, indicated by either positive resection margin (including suspected margin of the invaded organs) or positive postoperative lavage cytology.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eAdjuvant treatment\u003c/h2\u003e \u003cp\u003eFor patients who completed four cycles of neoadjuvant chemotherapy, S-1 was administered for one year after surgery. For patients who completed three cycles preoperatively, the fourth cycle of DCS was given postoperatively, followed by S-1 for 1 year.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eFollow-up\u003c/h2\u003e \u003cp\u003eThe follow-up schedule was in accordance with the JGCA guidelines [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Patients were followed up every 3-month for the first two years, every 6-month for the next three years, and then annually. The follow-up visit included a physical examination, laboratory blood tests, and abdominal ultrasonography. Computed tomography was performed every six months for the first three years and then annually. Endoscopy was performed every year. If a patient exhibited suggestive symptoms or signs of recurrence or metastasis, CT and/or endoscopy were performed irrespective of the scheduled follow-up.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003eWe investigated the short-tern outcomes including tumor response, completion of neoadjuvant chemotherapy, toxicity and adverse events, the rates of treatment-related death, R0 resection, the rate of complete adjuvant chemotherapy and short-term surgical results. The oncologic outcomes comprised 3-year OS and 3-year disease-free survival (DFS).\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eContinuous variables were summarized by mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or median (25th ; 75th percentiles), and categorical variables were summarized by the number of patients and percentage. Baseline characteristics were summarized for all patients and by three distinct groups: surgery, refuse surgery, and PD. OS and DFS were summarized using Kaplan-Meier method and visualized by the Kaplan-Meier curves. Cox model was used to compare OS and DFS between groups. Results were reported by hazard ratio (HR), 95% confidence interval (CI), and p-value. The DFS was analyzed for patients with R0 resection only. All analyses were done using R statistical software version 4.1.3. Univariable analysis was performed using two-sample t-test for normally distributed numeric variables, the Wilcoxon rank-sum test for non-normally distributed numeric variables, and Fisher's exact test for categorical variables. Multivariable analysis was conducted using logistic regression models with a stepwise backward procedure to identify independent risk factors of overall survival rate.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePatient\u0026rsquo;s characteristics\u003c/h2\u003e \u003cp\u003eThe clinico-pathological characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The mean age of the patients was 55.7\u0026thinsp;\u0026plusmn;\u0026thinsp;12.6 years, with a male-to-female ratio of 2:1. Among the participants, 11 patients (25.6%) had bulky lymph nodes, and 8 patients (18.6%) had para aortic lymph nodes involvement. The mean neoadjuvant chemotherapy tumor size was 3.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3 cm. Five patients (11.6%) had gastric outlet obstruction and underwent partitioning gastro-jejunostomy before receiving chemotherapy. Fifteen patients (34.9%) with anemia at the time of admission received blood transfusions until reaching the hemoglobin threshold of 10 g/dL.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll patients\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;43)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurgery\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRefuse surgery\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePD\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55.7\u0026thinsp;\u0026plusmn;\u0026thinsp;12.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.3\u0026thinsp;\u0026plusmn;\u0026thinsp;13.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57.7\u0026thinsp;\u0026plusmn;\u0026thinsp;14.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e52.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (67.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (72.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (69.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (40.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (32.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (28.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (30.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (60.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNutritional status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnderweight (BMI\u0026thinsp;\u0026lt;\u0026thinsp;18.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (16.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (23.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (40.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal weight (BMI:18.5\u0026ndash;24.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (74.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (84.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (61.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (60.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverweight (BMI:25\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (9.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObese (BMI\u0026thinsp;\u0026gt;\u0026thinsp;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (16.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (11.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiovascular disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (9.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic hepatic disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic lung disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic renal disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of laparotomy or\u003c/p\u003e \u003cp\u003elaparoscopic surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCEA (U/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3 (1.7; 9.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.3 (1.7; 8.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.0 (1.7; 11.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.5 (1.7; 5.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative WBC (g/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin (g/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (34.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (36.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (30.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (40.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGastric outlet obstruction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (11.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-CT tumor size (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifferentiation status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerately differentiated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (34.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (44.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (30.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoorly differentiated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (60.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (56.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (53.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (100.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSignet ring cell\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePara aorta lymph node\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (18.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (30.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (40.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical N stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (11.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (39.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (32.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (61.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (23.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (38.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (40.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBulky\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (25.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of CT cycles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (9.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (37.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (36.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (38.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (40.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (51.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (48.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (53.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (60.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResponse after 4 cycles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (58.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (72.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (53.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (30.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (28.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (46.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (11.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (100.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of follow-up (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.0 (13.3; 27.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.1 (16.8; 37.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.1 (9.3; 20.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.3 (8.1; 16.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eSummary statistics are mean\u0026thinsp;\u0026plusmn;\u0026thinsp;sd, n (%), and median (25th; 75th percentiles)\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eBMI: body mass index, CEA: carcinoembryonic antigen, WBC: white blood cell, CT: chemotherapy, CR: complete response, PR: partial response, SD: stable disease, PD: progress disease.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eTumor response\u003c/h2\u003e \u003cp\u003eThe total completion rate per protocol (3 or 4 cycles) was 88.4%, including 22 patients (51.2%) completed a course of 4 cycles and 16 patients (37.2%) underwent 3 cycles of neoadjuvant chemotherapy.\u003c/p\u003e \u003cp\u003eThe disease control rate was 88.4% (38 patients), including PR in 25 patients (58.1%) and SD in 13 patients (30.2%). There were no CR patients and 5 patients (11.6%) with PD. The clinical RR was 58.1% (all with PR). Twenty-five patients of those with PR or SD agreed to undergo gastrectomy and lymph node dissection, while the remaining 13 patients refused surgery. The patients who refused surgery continued with DCS regimen for enough 6 cycles and then received S-1 for 1 year.\u003c/p\u003e \u003cp\u003eAll 5 patients developed PD received second-line chemotherapy. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eToxicity and adverse events\u003c/h2\u003e \u003cp\u003eToxicity and adverse events are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. We observed four toxicities and adverse events with grade 3\u0026ndash;4, including neutropenia (8 patients [18.6%] with grade 3 and 1 patient [2.3%] with grade 4), anemia (5 patients [11.6%] with grade 3 and 1 patient [2.3%] with grade 4), hyponatremia (2 patients [4.8%] with grade 3), and vomiting (1 patient [2.3%] with grade 3). No treatment-related death was observed.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTreatment-related adverse event\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGrade 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGrade 2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGrade 3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGrade 4\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral fatigue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32 (74.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (20.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVomitting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35 (81.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (14.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiarrhoea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35 (81.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (16.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnorexia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42 (97.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRash\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePneumonitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38 (90.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1 (2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeripheral neuropathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41 (95.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStomatitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40 (93.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePigmentation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42 (97.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeukopenia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26 (60.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (25.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6 (14.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeutropenia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23 (53.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (14.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5 (11.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8 (18.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFebrile neutropenia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (37.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13 (30.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8 (18.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5 (11.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThrombocytopenia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41 (95.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElevated bilirubin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38 (88.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (11.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElevated SGOT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40 (93.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElevated SGPT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42 (97.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecreased BUN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42 (97.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProteinuria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41 (95.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypokalemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39 (92.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyponatremia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32 (76.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (19.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2 (4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eSummary statistics is n (%)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eOperative characteristics and short-term outcomes\u003c/h2\u003e \u003cp\u003eTwenty-five patients underwent gastrectomy and lymphadenectomy. Among them, distal gastrectomy was performed in 10 patients (40.0%), and total gastrectomy in 15 patients (60.0%). Seven patients underwent combined resection, including left hepatic segmentectomy (1 patient), segmental transverse colectomy (2 patients), and distal pancreato-splenectomy (4 patients). D2 resection was conducted in 21 patients (84.0%), D1\u0026thinsp;+\u0026thinsp;in 2 patients (8.0%), and D2\u0026thinsp;+\u0026thinsp;PAND in 2 patients (8.0%). R0 resection was achieved in 72.0% (18/25). There were 4 patients (16.0%) with R1 and 3 patients (12.0%) with R2 resection. The median number of harvested lymph nodes was 16 (12; 25). The overall complication rate was 24.0%, however, no patient occurred severe complications (Clavien Dindo\u0026thinsp;\u0026gt;\u0026thinsp;=\u0026thinsp;3). The rate of complete adjuvant chemotherapy was 83.3%. (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOperative characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurgery\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaparoscopy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (52.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (48.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative method\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistal gastrectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (40.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal gastrectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (60.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBorrmann\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (44.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (44.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (4.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical tumor size (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (4; 6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperating time (mins)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e215 (180; 250)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100 (50; 150)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombined surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (28.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombined surgery specification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft hepatic segmentectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (14.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSegmental transverse colectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (28.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistal pancreato-splenectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (57.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtent of lymph node dissection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD1+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (84.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD2\u0026thinsp;+\u0026thinsp;PAND\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of resected lymph nodes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (12; 25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathological T stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT4a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (56.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT4b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (16.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathological N stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (24.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (16.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (44.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN3a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (16.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN3b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (72.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (16.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (12.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdjuvant chemotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot complete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (83.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative hospital stay (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (7; 10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime to flatus (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2; 4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime to liquid diet (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2; 4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnastomotic leakage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnastomotic stricture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuodenal stump leakage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePancreatic fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (4.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParalytic ileus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (4.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntra-abdominal abscess\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEarly reoperation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiovascular complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePneumonitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (12.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary retention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (4.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClavien-Dindo classification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (12.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (12.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;= 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eSummary statistics are n (%), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;sd, and median (25th; 75th percentiles)\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003ePAND: para aortic lymph node dissection\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePathologic complete response was achieved in 2 patients (8.0%).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eLong-term survival outcomes\u003c/h2\u003e \u003cp\u003eThe median (25th ; 75th percentiles) length of follow-up was 19.0 (13.3; 27.9) months in the total study population, and 24.1 (16.8; 37.8) months in the surgery group. There were 27 deaths in the total population and 12 deaths in the surgery group.\u003c/p\u003e \u003cp\u003eThe 1-, 2-, and 3-year OS rates (95% CI) of the surgery group were 92% (82;100%), 65% (48;88%), and 49% (32;76%), respectively. The 1-, 2-, and 3-year OS rates (95% CI) of the refuse-surgery group were 76% (56;100), 8.5% (1.3;55), and 0%, respectively. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe 1-, 2-, and 3-year DFS rates (95% CI) of the R0 group were 72 (54; 96), 48 (29; 79), and 38 (19, 75), respectively.\u003c/p\u003e \u003cp\u003eFor surgery group, the results from the univariable analyses showed that pathological lymph node stage, and incomplete adjuvant chemotherapy were identified to significantly reduce the overall survival. However, in the multivariable analyses, no independent risk factors were found to reduce the overall survival. (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariable and multivariable analysis of factors associated with OS (surgery group)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eUnivariable model\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eMultivariable model\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.97, 1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.393\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.72, 7.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.163\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre- CT tumor size (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.69, 1.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.607\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBorrmann\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.53, 2.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.880\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePara aorta lymph node\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.63, 14.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifferentiation status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerately differentiated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoorly differentiated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.60, 6.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.260\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSignet ring cell\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaparoscopy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.28, 2.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.802\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative method\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistal gastrectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal gastrectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.71, 8.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResponse after 4 cycles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.09, 1.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathological T stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epT0-T3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epT4a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.31, 5.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.757\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epT4b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.46, 11.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.304\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathological N stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epN0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epN1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.14, 53.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.037\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.90, 139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.060\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epN2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.41, 10.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.377\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.37, 27.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.293\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epN3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.16, 20.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.623\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.22, 61.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.365\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR1/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.19, 2.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.584\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombined surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.24, 3.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.855\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdjuvant chemotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo/incomplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.22, 22.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.026\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.76, 16.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.109\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 3\u0026ndash;4 adverse event\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.58, 6.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.278\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eHR: hazard ratio, CI: confidence interval, CT: chemotherapy, PR: partial response, SD: stable disease\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eRecurrence pattern after surgery\u003c/h2\u003e \u003cp\u003eThirteen patients (52.0%) of the surgery group occurred recurrence and or metatstasis, including locaregional recurrence (1 patients), hematogenous (1 patients), peritoneum (2 patients), distant lymph node (1 patients), and mixed type (8 patients).\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003ePatients of GC with T4b stage, gastrectomy and additional combined resection may be the only way for a potential cure. However, radical resection for cT4b gastric cancer may increase potential postoperative complications and carries a high risk of R1/R2 resection, especially when pancreatic head or liver are involved. Moreover, GC at the T4b stage often presents with high lymph nodes metastasis and peritoneal spread, which contribute to poorly survival outcomes [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Therefore, multivisceral resection for T4b gastric cancer remains controversial. This disorder should be treated as a separate group to achieve better survival outcomes.\u003c/p\u003e \u003cp\u003eIn our study, we expected to improve long-term survival and minimize the toxicity and adverse events of patients with T4b GC by applying neoadjuvant chemotherapy with DCS regimen, followed by gastrectomy and lymphadenectomy. The findings demonstrated much better efficacy than initially anticipated, with high compliance rate (88.4%), R0 resection rate (72.0%), low toxicities and adverse events, and satisfactory survival (3-year OS of 49%). These results enhanced the use of neoadjuvant chemotherapy with DCS regimen followed by gastrectomy and lymphadenectomy in this population, which has not been reported before.\u003c/p\u003e \u003cp\u003eBesides the regimen for neoadjuvant chemotherapy, the dosage is also a critical factor in increasing the response rate and reducing toxicity. In Japan, a 2\u0026ndash;3 cycle DCS (docetaxel, cisplatin and S-1) or CS (cisplatin and S-1) regimen was utilized for preoperative chemotherapy for GC with advanced stage or extended lymph node metastasis. However, there were a relatively high incidence of grade 3 or grade 4 toxicity and adverse events, particularly leukopenia (18.9\u0026ndash;27.5%), neutropenia (19.0\u0026ndash;55.0%), diarrhea (7.5\u0026ndash;10%) [\u003cspan additionalcitationids=\"CR33 CR34 CR35\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. A higher dose of docetaxel and cisplatin was supposed to be related to a higher incidence of grade 3\u0026ndash;4 hematological toxicity [\u003cspan additionalcitationids=\"CR42\" citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. In our study, the total dose of docetaxel (70 mg/m\u003csup\u003e2\u003c/sup\u003e/cycle) and cisplatin (70mg/m\u003csup\u003e2\u003c/sup\u003e/cycle), which was higher than in other studies, was adjusted by dividing it into biweekly schedules to reduce toxicity adverse effects. The dose intensity of docetaxel (17.5 mg/m\u003csup\u003e2\u003c/sup\u003e/week), cisplatin (17.5 mg/m\u003csup\u003e2\u003c/sup\u003e/week), and S-1 (280 mg/m\u003csup\u003e2\u003c/sup\u003e/week) were relatively higher in other trials. However, most of the toxicity and adverse events were in grade 1 or 2, while grade 3 or 4 of neutropenia and anemia were 20.9%, and 13.9%, respectively. These results were remarkably lower than reported in the other studies. Thus, a high completion and tolerance rate was obtained in our study population with this modified schedule.\u003c/p\u003e \u003cp\u003eRegarding postoperative complications of gastrectomy and radical lymphadenectomy after neoadjuvant chemotherapy, the overall complication rate in our study was similar to several prior studies [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan additionalcitationids=\"CR44 CR45\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. However, no patient experienced severe complications (ClavienDindo\u0026thinsp;\u0026gt;\u0026thinsp;=\u0026thinsp;3) in this study. Performing a radical resection for cT4b gastric cancer without neoadjuvant chemotherapy may increase the complexity of the operation and pose potential postoperative complications in certain cases, particularly when the pancreas and liver are involved. Some authors hypothesized that extensive resection was linked to a higher incidence of overall severe complications and mortality [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Conversely, recent studies support the notion that there is no disparity in postoperative complications between multivisceral resection and gastrectomy alone [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In our study, seven patients underwent combined resection, 21 patients underwent D2 resection, 2 patients underwent D1\u0026thinsp;+\u0026thinsp;resection, and 2 patients underwent D2\u0026thinsp;+\u0026thinsp;PAND. We didn't have any cases of severe complications such as anastomotic leak, bleeding, or severe complications after surgery. The feasibility and safety of extended gastrectomy were previously advocated, and our results are relatively better to those without neoadjuvant chemotherapy reported in the literature [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe adjuvant chemotherapy approach is required to improve the curability and survival outcome for T4b GC. Although MVR was considered safe and feasible with high rate of R0 resection for T4b gastric cancer, several previous studies demonstrated that initiation of adjuvant chemotherapy might be prolonged or even prohibited due to patient derailing after a large MVR. The rate of adjuvant chemotherapy was low (41\u0026ndash;75%), resulting in unsatisfactory survival outcomes with 3-year OS of 10.8\u0026ndash;39.0% [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In this manner, our study was among the limited data demonstrating the efficacy of neoadjuvant chemotherapy for T4b GC, with high rate of complete adjuvant chemotherapy (83.3%), low toxicities and morbidities, and satisfactory 3-year OS (49%) and DFS (38%). These findings were superior to those of previous studies, in which MVR surgery was performed without neoadjuvant chemotherapy [\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Based on these results, we suggest applying neoadjuvant chemotherapy with DCS regimen over upfront surgery and adjuvant chemotherapy for T4b GC.\u003c/p\u003e \u003cp\u003eAnalyzed by univariate regression, our findings indicated that pathological lymph node stage and incomplete adjuvant chemotherapy significantly reduced the overall survival. However, due to the small sample size, the multivariable analyses did not reveal any independent risk factors. Several previous studies have identified the incompleteness of resection, lymph node metastasis, and the number of resected organs as independent prognostic factors for T4b GC. Among these, the most powerful prognostic factor was the completeness of resection, which has been confirmed by almost all the published studies [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8 CR9 CR10\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study had some limitations. Firstly, although the findings were potential, it was still a single-arm retrospective study at a single institution. Thus, controlled trials are required to propose a stronger recommendation. Secondly, the 5-year survival outcomes could not be evaluated in this study. We expected to report these outcomes in further study after a sufficient length of follow-up. Thirdly, the number of patients included in this study was relatively small when divided into separate groups, and further evaluations are required in larger populations.\u003c/p\u003e \u003cp\u003e In conclusion, neoadjuvant chemotherapy with DCS regimen followed by gastrectomy and lymphadenectomy demonstrated a high tolerance, high tumor response rate, sufficient R0 resection rate, high complete adjuvant chemotherapy rate and satisfactory 3-year survival outcomes for GC with T4b. Preoperative DCS regimen with 3\u0026ndash;4 cycles was a promising approach for GC with T4b stage.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDrs. Vo Duy Long, Dang Quang Thong, Tran Quang Dat, Doan Thuy Nguyen, Tran Duy Phuoc, Nguyen Viet Hai, Nguyen Lam Vuong, Lam Quoc Trung and Nguyen Hoang Bac disclose any potential or actual personal, political or financial conflict of interest in the material, information or techniques described in the paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u2028\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted according to the guidelines of the Declaration of Helsinki and approved by Institutional Review Board, University Medical Center Ho Chi Minh city.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eApproval to perform research on human subjects in this study was provided by the Institutional Review Board, University Medical Center Ho Chi Minh city (registration number: 37/HDDD-DHYD)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data presented in this study are available on request from the corresponding author.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWang GC, et al. Surgical outcomes and survival for T4 gastric cancer extending to the transverse colon. Ann Transl Med 2020;8:947.\u003c/li\u003e\n \u003cli\u003eOzer I, et al. Surgical outcomes and survival after multiorgan resection for locally advanced gastric cancer. Am J Surg 2009;198:25-30.\u003c/li\u003e\n \u003cli\u003eMita K, et al. Surgical outcomes and survival after extended multiorgan resection for T4 gastric cancer. Am J Surg 2012;203:107-11.\u003c/li\u003e\n \u003cli\u003eZhang X, et al. Short-term safety and Long-term efficacy of multivisceral resection in pT4b gastric cancer patients without distant metastasis: a 20-year experience in China National Cancer Center. J Cancer 2022;13:3113-20.\u003c/li\u003e\n \u003cli\u003eMita K, et al. Prognostic Factors Affecting Survival After Multivisceral Resection in Patients with Clinical T4b Gastric Cancer. J Gastrointest Surg 2017;21:1993-9.\u003c/li\u003e\n \u003cli\u003eSahakyan M, et al. Extended Gastrectomy for T4b Gastric Adenocarcinoma: Single-Surgeon Experience. J Gastrointest Cancer 2020;51:135-43.\u003c/li\u003e\n \u003cli\u003eJin P, et al. Retrospective analysis of surgically treated pT4b gastric cancer with pancreatic head invasion. World J Clin Cases 2021;9:8718-28.\u003c/li\u003e\n \u003cli\u003eCarboni F, et al. Extended multiorgan resection for T4 gastric carcinoma: 25-year experience. J Surg Oncol 2005;90:95-100.\u003c/li\u003e\n \u003cli\u003eAversa JG, et al. Multivisceral Resection for Locally Advanced Gastric Cancer. J Gastrointest Surg 2021;25:609-22.\u003c/li\u003e\n \u003cli\u003ePacelli F, et al. Multivisceral resection for locally advanced gastric cancer: an Italian multicenter observational study. JAMA Surg 2013;148:353-60.\u003c/li\u003e\n \u003cli\u003eYang Y, et al. Multivisceral resection for locally advanced gastric cancer: A retrospective study. Am J Surg 2021;221:1011-7.\u003c/li\u003e\n \u003cli\u003eTran TB, et al. Multivisceral Resection for Gastric Cancer: Results from the US Gastric Cancer Collaborative. Ann Surg Oncol 2015;22 Suppl 3:S840-7.\u003c/li\u003e\n \u003cli\u003eLee CM, et al. How Does Combined Resection Affect the Clinical Outcomes After Laparoscopic Surgery for Serosa-Positive Gastric Cancer?: A Retrospective Cohort Study to Investigate the Short-Term Outcomes of Laparoscopic Combined Resection in Patients With T4b Gastric Cancer. Front Oncol 2019;9:1564.\u003c/li\u003e\n \u003cli\u003eBrar SS, et al. Multivisceral resection for gastric cancer: a systematic review. Gastric Cancer 2012;15 Suppl 1:S100-7.\u003c/li\u003e\n \u003cli\u003eDias AR, et al. Prediction scores for complication and recurrence after multivisceral resection in gastric cancer. Eur J Surg Oncol 2020;46:1097-102.\u003c/li\u003e\n \u003cli\u003eFavacho BC, et al. T4b gastric carcinoma: 12 years of experience at an University Hospital. Arq Bras Cir Dig 2013;26:268-73.\u003c/li\u003e\n \u003cli\u003eVladov N, et al. Аre Multivisceral Resections for Gastric Cancer Acceptable: Experience from a High Volume Center and Extended Literature Review? Surg J (N Y) 2023;9:e28-e35.\u003c/li\u003e\n \u003cli\u003eMin JS, et al. Prognosis of curatively resected pT4b gastric cancer with respect to invaded organ type. Ann Surg Oncol 2012;19:494-501.\u003c/li\u003e\n \u003cli\u003eSchizas D, et al. Multivisceral Resection for Locally Advanced Gastric Cancer: A Systematic Review and Evidence Quality Assessment. J Clin Med 2023;12.\u003c/li\u003e\n \u003cli\u003eKunisaki C, et al. Surgical outcomes in patients with T4 gastric carcinoma. J Am Coll Surg 2006;202:223-30.\u003c/li\u003e\n \u003cli\u003eKim DY, et al. T4 gastric carcinoma: the benefit of non-curative resection. ANZ J Surg 2006;76:453-7.\u003c/li\u003e\n \u003cli\u003eHayashi T, et al. Primary results of a randomized two-by-two factorial phase II trial comparing neoadjuvant chemotherapy with two and four courses of cisplatin/S-1 and docetaxel/cisplatin/S-1 as neoadjuvant chemotherapy for advanced gastric cancer. Ann Gastroenterol Surg 2020;4:540-8.\u003c/li\u003e\n \u003cli\u003eReddavid R, et al. Neoadjuvant chemotherapy for gastric cancer. Is it a must or a fake? World J Gastroenterol 2018;24:274-89.\u003c/li\u003e\n \u003cli\u003eKodera Y. Neoadjuvant chemotherapy for gastric adenocarcinoma in Japan. Surg Today 2017;47:899-907.\u003c/li\u003e\n \u003cli\u003eIrino T, et al. Essential updates 2019/2020: Perioperative and surgical management of gastric cancer. Ann Gastroenterol Surg 2021;5:162-72.\u003c/li\u003e\n \u003cli\u003eTokunaga M, et al. Neoadjuvant chemotherapy for locally advanced gastric cancer in Japan: Consensus meeting at the 77th general meeting of the Japanese Society of Gastroenterological Surgery. Ann Gastroenterol Surg 2023;7:856-62.\u003c/li\u003e\n \u003cli\u003eCunningham D, et al. Capecitabine and oxaliplatin for advanced esophagogastric cancer. N Engl J Med 2008;358:36-46.\u003c/li\u003e\n \u003cli\u003eAl-Batran SE, et al. Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel versus fluorouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric or gastro-oesophageal junction adenocarcinoma (FLOT4): a randomised, phase 2/3 trial. Lancet 2019;393:1948-57.\u003c/li\u003e\n \u003cli\u003eAl-Batran SE, et al. Biweekly fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT) for patients with metastatic adenocarcinoma of the stomach or esophagogastric junction: a phase II trial of the Arbeitsgemeinschaft Internistische Onkologie. Ann Oncol 2008;19:1882-7.\u003c/li\u003e\n \u003cli\u003eSmyth EC, et al. Gastric cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2016;27:v38-v49.\u003c/li\u003e\n \u003cli\u003eCunningham D, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med 2006;355:11-20.\u003c/li\u003e\n \u003cli\u003eTsuburaya A, et al. Neoadjuvant chemotherapy with S-1 and cisplatin followed by D2 gastrectomy with para-aortic lymph node dissection for gastric cancer with extensive lymph node metastasis. Br J Surg 2014;101:653-60.\u003c/li\u003e\n \u003cli\u003eIto S, et al. A phase II study of preoperative chemotherapy with docetaxel, cisplatin, and S-1 followed by gastrectomy with D2 plus para-aortic lymph node dissection for gastric cancer with extensive lymph node metastasis: JCOG1002. Gastric Cancer 2017;20:322-31.\u003c/li\u003e\n \u003cli\u003eKurokawa Y, et al. Short-term outcomes of preoperative chemotherapy with docetaxel, oxaliplatin, and S-1 for gastric cancer with extensive lymph node metastasis (JCOG1704). Gastric Cancer 2024.\u003c/li\u003e\n \u003cli\u003eSato Y, et al. A Phase II study of preoperative chemotherapy with docetaxel, oxaliplatin and S-1 in gastric cancer with extensive lymph node metastasis (JCOG1704). Future Oncol 2020;16:31-8.\u003c/li\u003e\n \u003cli\u003eTsuchida K, et al. Short-term results of a phase II study of preoperative docetaxel/cisplatin/S-1 therapy for locally advanced gastric cancer. Jpn J Clin Oncol 2021;51:371-8.\u003c/li\u003e\n \u003cli\u003eTherasse P, et al. New guidelines to evaluate the response to treatment in solid tumors. European Organization for Research and Treatment of Cancer, National Cancer Institute of the United States, National Cancer Institute of Canada. J Natl Cancer Inst 2000;92:205-16.\u003c/li\u003e\n \u003cli\u003eTrotti A, et al. CTCAE v3.0: development of a comprehensive grading system for the adverse effects of cancer treatment. Semin Radiat Oncol 2003;13:176-81.\u003c/li\u003e\n \u003cli\u003eJapanese gastric cancer treatment guidelines 2018 (5th edition). Gastric Cancer 2021;24:1-21.\u003c/li\u003e\n \u003cli\u003eJapanese Gastric Cancer Treatment Guidelines 2021 (6th edition). Gastric Cancer 2023;26:1-25.\u003c/li\u003e\n \u003cli\u003eHolleran WM and DeGregorio MW. Evolution of high-dose cisplatin. Invest New Drugs 1988;6:135-42.\u003c/li\u003e\n \u003cli\u003eHarvey V, et al. Phase III trial comparing three doses of docetaxel for second-line treatment of advanced breast cancer. J Clin Oncol 2006;24:4963-70.\u003c/li\u003e\n \u003cli\u003eEsposito M, et al. Protective effect on cisplatin hematotoxicity by procaine hydrochloride. Cancer Lett 1992;64:55-60.\u003c/li\u003e\n \u003cli\u003eKhaled I, et al. Oncological outcomes of laparoscopic versus open gastrectomy after neoadjuvant chemotherapy for locally advanced gastric cancer: a retrospective multicenter study. World J Surg Oncol 2021;19:206.\u003c/li\u003e\n \u003cli\u003eT\u0026eacute;oule P, et al. Impact of Neoadjuvant Chemotherapy on Postoperative Morbidity after Gastrectomy for Gastric Cancer. Dig Surg 2015;32:229-37.\u003c/li\u003e\n \u003cli\u003eUmeda S, et al. Short-term outcomes of gastrectomy after neoadjuvant chemotherapy for clinical stage III gastric cancer: propensity score-matched analysis of a multi-institutional database. Surg Today 2021;51:821-8.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-surgical-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjso","sideBox":"Learn more about [World Journal of Surgical Oncology](http://wjso.biomedcentral.com)","snPcode":"12957","submissionUrl":"https://submission.nature.com/new-submission/12957/3","title":"World Journal of Surgical Oncology","twitterHandle":"@OncoBioMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Gastric cancer, Neoadjuvant chemotherapy, T4b stage, Clinical response rate, DCS regimen","lastPublishedDoi":"10.21203/rs.3.rs-4985426/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4985426/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e No studies on neoadjuvant chemotherapy for gastric cancer (GC) with T4b stage were reported. This study aimed to assess the effectiveness of neoadjuvant chemotherapy using DCS regimen (docetaxel, cisplatin, and S-1) for GC with T4b stage\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Forty-three patients diagnosed GC with surgical or clinical T4b stage received three or four preoperative cycles of DCS therapy followed by gastrectomy and lymphadenectomy between Jan-2018 and Dec-2022. Short-tern outcomes including tumor response, completion of neoadjuvant chemotherapy, toxicity and adverse events, rate of treatment-related death, R0 resection, rate of complete adjuvant chemotherapy and short-term surgical results were investigated. The oncologic outcomes comprised 3-year OS and 3-year disease-free survival (DFS).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe completion rate of neoadjuvant chemotherapy was 88.4%, including 4 cycles of 51.2% and 3 cycles of 37.2%. The disease-control and clinical response rate were 88.4% and 58.1%, respectively. During preoperative chemotherapy, grade 3/4 neutropenia occurred in 20.9%, anemia in 13.9%, hyponatremia in 4.8%, and vomiting in 2.3%. Pathologic complete response was achieved in 8.0%. After surgery, no patient experienced severe complications (Clavien Dindo \u0026gt;= 3). The R0 resection rate was 72.0% and the rate of complete adjuvant chemotherapy was 83.3%. The 3-year OS and DFS rates were 49% and 38%, respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Neoadjuvant chemotherapy with DCS regimen demonstrated a high tolerance, high tumor response rate, high complete adjuvant chemotherapy rate and satisfactory 3-year survival outcomes. Three- or four-course of preoperative DCS regimen is a promising approach for GC with T4b stage.\u003c/p\u003e","manuscriptTitle":"Effectiveness of Neoadjuvant Chemotherapy with a Docetaxel, Cisplatin, and S-1 (DCS) Regimen for T4b Gastric Cancer","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-17 13:58:38","doi":"10.21203/rs.3.rs-4985426/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-17T16:45:51+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-13T09:54:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-11T08:11:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-10T18:18:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-06T15:34:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"311108809953280276982840619941131436730","date":"2024-11-04T17:44:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"77654344726743417742631603805114612057","date":"2024-11-03T14:09:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"238078718974077849134224116415484067174","date":"2024-11-01T20:47:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"209415328790788972996247063775743305051","date":"2024-11-01T19:03:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"147159973170018703203654520141000929111","date":"2024-10-31T01:03:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"298449206714169691033921953025707254999","date":"2024-10-30T20:08:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-29T15:33:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"196252889810305657773218102009444160361","date":"2024-10-23T07:32:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"131604022118997706495716628981709116077","date":"2024-10-21T13:59:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"207046948406159268538267262073891245432","date":"2024-10-20T03:29:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"179054095036738021735476837687515113670","date":"2024-10-19T18:02:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"181633633751281249589120407203360608341","date":"2024-10-13T10:09:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-09-01T07:44:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-01T03:41:55+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-28T12:35:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"World Journal of Surgical Oncology","date":"2024-08-27T14:53:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-surgical-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjso","sideBox":"Learn more about [World Journal of Surgical Oncology](http://wjso.biomedcentral.com)","snPcode":"12957","submissionUrl":"https://submission.nature.com/new-submission/12957/3","title":"World Journal of Surgical Oncology","twitterHandle":"@OncoBioMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c412a00a-681a-4a78-839e-418caefd2072","owner":[],"postedDate":"October 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-23T16:06:06+00:00","versionOfRecord":{"articleIdentity":"rs-4985426","link":"https://doi.org/10.1186/s12957-024-03620-1","journal":{"identity":"world-journal-of-surgical-oncology","isVorOnly":false,"title":"World Journal of Surgical Oncology"},"publishedOn":"2024-12-20 15:58:31","publishedOnDateReadable":"December 20th, 2024"},"versionCreatedAt":"2024-10-17 13:58:38","video":"","vorDoi":"10.1186/s12957-024-03620-1","vorDoiUrl":"https://doi.org/10.1186/s12957-024-03620-1","workflowStages":[]},"version":"v1","identity":"rs-4985426","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4985426","identity":"rs-4985426","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}