Introduction

The 10th Congress of the International Gastric Cancer Association (IGCA), focusing on “Tailored and multidisciplinary gastric cancer treatment,” was held in Verona on 19–22 June 2013. An important scientific event in the annual calendar of physicians working in this area, the congress attracts participants from various medical disciplines. This year the Scientific Committee aimed to broaden the discussion to involve as many professional figures as possible, e.g., surgeons, pathologists and, gastroenterologists, oncologists, epidemiologists, medical statisticians, nutritionists, molecular biologists and radiotherapists.

A sizeable percentage of researchers publishing important articles on gastric cancer do not attend the IGCA Congress (IGCC), and discussion of their papers is often confined to Letters to the Editor of the journals in which the articles have been published. While interesting debates on specific papers are often held during IGCA Congresses, they are obviously limited to congress participants, and their contents are not available to the scientific community as a whole.

In an attempt to overcome these limitations, the Scientific Committee of the 10th IGCC decided to organize several pre-congress Web Round Tables to discuss a number of cutting-edge topics relating to gastric cancer treatment. To this end, researchers who had recently published high-quality articles were invited to participate by sending a comment on their studies and by responding to participants’ queries in the Web discussions during the months leading up to the event. Many of the authors and participants subsequently attended the congress to continue the dialog begun in the virtual sessions, an opportunity much appreciated by the younger professionals as it increased their impression of being personally involved in the proceedings.

The present article summarizes the results of this initiative.

The Web Round Table project

A number of Web Round Tables, each one coordinated by a chairman, were proposed on the Congress website about 1 year before the date of the Congress (http://www.10igcc.com/). The chairmen invited a panel of international experts to provide support as co-chairmen, in particular to discuss the aim of the Web Round Tables in advance and to stimulate debate when appropriate during the online events. Each chairman first identified 20–30 important studies that were pertinent to the theme of his/her Round Table. The corresponding authors of these articles were then asked to re-evaluate the conclusions of their published works in light of their subsequent experience and knowledge and to send back an update that would form the basis of discussion of the Web Round Tables. The chairmen posted several questions on the web and opened a forum for a period of 1–2 months. The forum was free and specifically intended for congress participants. Access to the Web Round Tables was granted after free pre-registration in which information was collected on the country and institutional affiliation of the participant. The chat tool and a chairman filter were not used in order to avoid private debate, patient participation and direct advertising inside the debate, this last being possible in other parts of the website.

Results

Twenty Round Tables were proposed (Table 1) and conducted between February and July 2012. Of the 516 authors who were invited to participate, 51 (9.9 %) sent back a re-evaluation of their published articles. About 4,500 informative e-mails were sent out by the congress secretary or chairmen to IGCA members, medical colleagues and other professionals involved in the area of gastric area. Two hundred fifty participants from 21 countries joined the forum discussion and posted 671 comments, now freely available for consultation on the Congress website. Discussion was varied and interesting, leading to conclusions that can also viewed online. The Web Round Tables were viewed 15,810 times while the forum was open. Both the number of comments posted (Fig. 1) and the number of visits to the website (Fig. 2) varied widely across the different Web Round Tables.

Table 1 List of Web Round Tables with corresponding chairmen
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Fig. 1
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Active participation in the various Web Round Tables evaluated by number of comments posted

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Fig. 2
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Number of visits to each Web Round Table

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Brief conclusions drawn by the Chairmen of the seven Web Round Tables that elicited the greatest interest on the basis of the number of posts and/or visits are reported below:

  • Follow-up for diagnosis of recurrence and late complications: clinical utility?

  • Different neoadjuvant treatments for Eastern and Western patients?

  • Gastric GIST. Is resection always indicated?

  • TNM Staging after neoadjuvant chemotherapy

  • Resection margins and prognosis

  • How to predict recurrence and prognosis

  • Extended criteria for ESD.

The first Web Round Table proposed dealt with Recurrence and prognosis (chairman: Alberto Di Leo). The clinical usefulness of two instruments recently proposed to improve the prediction of patient outcome after resection for gastric cancer was presented. The first instrument was a postoperative nomogram developed in the US, while the second was a prognostic score proposed by GIRCG (Italian Group for Research on Gastric Cancer). Discussion on the web underlined that these tools have proven more effective than the UICC/AJCC staging system and could thus facilitate decision-making for adjuvant treatment. However, neither of these models has been introduced into clinical practice in European institutions. Furthermore, they cannot be proposed as a standard method to predict outcome because of their limits in comparing treatment results from different international settings. Indeed, factors relating to patient, tumor and treatment vary among institutions, especially between East and West, and the Web Discussion highlighted the importance of treatment standardization before applying scores. Another limit of these instruments is that they rely on postoperative variables, making their use inappropriate in a preoperative setting and in neoadjuvant treatment decision-making. However, despite their limitations, the two statistical models could be used to compare results from centers that use similar surgical strategies and treat similar types of patients.

An interesting discussion involving endoscopists, pathologists and surgeons ensued from the Web Round Table on Extended criteria for endoscopic resections (chairman: Luca Saragoni). The experts were in complete agreement that endoscopic mucosal resection (EMR) still plays a role in early gastric cancer (EGC) treatment in about 5 % of cases and only for small tumors of up to 5 mm, especially when located in the greater curvature of the upper gastric body. All participants agreed that endoscopic submucosal dissection (ESD) should be the primary method used to treat EGC, Western countries following the Japanese Guideline criteria [2] and Eastern countries, the National Cancer Center extended criteria [3]. This difference emerged because ESD is also performed in the West, but only in specialist centers and by skilled endoscopists with adequate training. Conversely, not all participants felt that confirmatory multicentric prospective studies on extended criteria were needed.

Resection margins and prognosis (chairman: Giuliano La Barba). This Web Round Table was proposed because of the impact of resection margins on prognosis and also because of the different approaches used for positive margins after endoscopic or surgical resection. Chromoendoscopy with indigo carmine is recommended to avoid lateral positive margins in ESD and for preoperative diagnoses. Conversely, intraoperative diagnosis on frozen sections, which is not feasible after endoscopic treatment, is advisable in selected surgically treated patients and is performed using cytokeratins (fast staining).

After ESD, if histologic assessment of the resected specimen reveals a positive lateral margin but all the other histologic criteria for endoscopic resection have been met, some expert endoscopists propose endoscopic re-treatment with ESD. Others draw attention to the technical difficulties caused by fibrosis and underline the importance of highly skilled operators for the procedure. Surgeons recommend surgical resection with lymph node dissection for these patients. All participants were in complete agreement about the fact that, if deep margins are involved, surgical treatment is indicated.

Various treatment options have been hypothesized when the resection line is involved after surgical treatment. Some surgeons recommend additional resection if R0 surgery is feasible, even in T2-T3 and N0-2 patients, whereas others propose only radio-chemotherapy in advanced cancer.

A number of participants proposed the N ratio as a criterion to select patients for surgical re-treatment. Recently, sclerotic margins have been observed in patients responding to neoadjuvant therapy. In such cases surgeons suggest performing subtotal or total gastrectomy in relation to the site of the original tumor. However, all the Round Table participants agreed that, where possible, it is better to resect all sclerotic margins.

An interesting, well-attended Web Round Table was held on Follow-up for diagnosis of recurrence and late complications: clinical utility? (chairman: Luca Baiocchi). The role of follow-up after radical gastrectomy for cancer is a much debated issue, with two opposing schools of thought. On the one hand, some participants do not propose follow-up because they agree with several monocentric retrospective studies that have clearly shown that early diagnosis of tumor recurrence in the asymptomatic phase does not improve survival with respect to late diagnosis motivated by symptoms. Conversely, others work in high-volume centers for gastric cancer surgery that provide programmed clinical and instrumental follow-up to minimize the nutritional sequelae of gastrectomy and ensure a timely diagnosis of tumor recurrence. The latter approach is based on the premise that biomedical research will eventually lead to more effective therapeutic options for metastatic and/or relapsed patients and that regular evaluation of therapeutic achievements, especially with regard to survival and recurrence, is a prerequisite for the improvement of quality standards in surgical oncology. Numerous participants also underlined that scheduled follow-up visits do not represent a source of stress in the majority of patients; on the contrary, patients feel protected and reassured by the frequency of these checkups. In this specific area, substantial differences were noted between participants originating from different geographical areas; in particular, it emerged that authors from Japan and Korea, Italy, Brazil, Germany and France frequently perform clinical evaluation and request instrumental exams, whereas those from Eastern Europe, Peru and India tend to limit follow-up to clinical assessment. It was also revealed that surgeons from England and the USA often carry out instrumental follow-up in a rather limited manner or reserve it for patients taking part in experimental studies.

Different modes of follow-up were also reported: although it was generally acknowledged that the CT scan is the method of choice to detect recurrence, many participants limit follow-up to clinical and biochemical examinations. However, all agreed on the usefulness of a debate in which different attitudes could be compared.

Another area that stimulated lively discussion was TNM staging after neoadjuvant chemotherapy (chairman: Anna Tomezzoli). Neoadjuvant treatment alters the tumor architecture, and pathologic staging classification is of the utmost importance to define the response to treatment (the TNM system is only a valid option to define N status or to stage the disease when the cancer has completely disappeared [ypT0]). On the other hand, the UICC classification is unable to categorize other potential alterations in the structure of the tumor and, in particular, fails to define partial response. Participants agreed that, after neoadjuvant chemotherapy, residual cancer may be confined to some of the deeper layers of the gastric wall, sparing the more superficial ones. There was general agreement among Web Round Table participants that wall involvement should be considered as a greater depth of invasion and is probably indicative of a poorer prognosis.

However, the regression grade is also of paramount importance to define prognostic groups. Although most information available comes from data collected on esophageal and esophagogastric junction carcinomas, it is hypothesized that a response classification may also be important in gastric cancer. As reported by Becker et al. [4], major tumor regression is rarely achieved in distal gastric cancer. In this respect, it would be important to divide partial responders into groups with different prognoses. However, Web Round Table discussion did not reveal a consensus on the most suitable grading system for esophageal or gastric cancer. Similarly, no standard guidelines have been established as yet for the treatment of pathologic specimens.

Gastric GIST. Is resection always indicated? (chairman: Filippo Catalano). The endoscopic treatment of gastrointestinal stromal tumors (GIST) is the subject of great debate within the international medical community. Surgical resection plays a fundamental role in large tumors, whereas clinical follow-up is standard practice in smaller lesions. The recent introduction of ESD has opened up new frontiers in the management of these tumors. The Web Round Table participants were in complete agreement about the feasibility of this technique but acknowledged that it requires confirmation in larger case series. Moreover, before ESD is universally accepted as a definitive procedure, its long-term efficacy needs to be evaluated in studies with a longer follow-up.

Endoscopic ultrasound (EUS) can provide a highly accurate description of the size and site of the tumor, and such information is of prime importance when endoscopic treatment by ESD is hypothesized. However, participants agreed that when the lesion is less than 2 cm, EUS cannot provide sufficient information on its biology, even when accompanied by fine-needle aspiration; the latter is normally used to define the histology of a GIST, but not its biological features. Histological criteria for GIST definition can only be verified in en bloc resected specimens from endoscopic or surgical procedures. KRAS and BRAF mutational analysis can also provide an important contribution to permit tailored treatment of advanced GISTs.

Surgical treatment should always be considered for high-risk GISTs, even those completely resected by ESD.

Different neoadjuvant treatments for Eastern and Western patients? (chairman Gianni Mura). Surgery alone is not sufficient for the treatment of advanced gastric cancer. In the light of promising results obtained from a number of international trials, a multimodal approach including neoadjuvant treatment is now often offered to such patients. The majority of participants in this Web Round Table agreed that tumors in different sites, e.g., distal esophageal or junctional vs. stomach, may show different biological behavior and respond differently to treatments, and this may have led to a biased evaluation of results from past clinical trials. During the discussion, it was also acknowledged that, excluding these biases, neoadjuvant chemotherapy shows promising results. Studies are ongoing to evaluate the efficacy of novel drugs, new drug sequences and radiotherapy.

The therapeutic possibilities linked to the use of biological agents were underlined by participants. It emerged that the most promising area, albeit without proven clinical application as yet, is the selection of patients for chemotherapy on the basis of biologic and genetic factors, which would open the way for individually tailored therapy. It was concluded that multi-targeted rather than single-targeted treatment is probably needed for gastric cancer.

While neoadjuvant treatment is frequently proposed in the West, Eastern countries prefer a different approach. In fact, surgery alone in the East shows excellent survival rates, and even better results have been observed using S-1 as adjuvant treatment. Consequently, preoperative treatment in Eastern countries is mainly confined to patients with unresectable gastric cancer in order to make radical surgery possible. Randomized trials are currently ongoing in an attempt to shed more light on these issues.

Discussion

The Web Round Tables aroused considerable interest, especially among young professionals working in the area of gastric cancer. It was, in fact, the first time that such an event had been proposed on a congress website. Discussants had the opportunity to contact and interact with experts in an often interesting and lively debate. All the discussions are now freely available for consultation at http://www.10igcc.com/forum. The replies from the 51 authors who responded to the chairmen’s invitation to provide an update of their previously published studies can also be viewed online in the Bibliography link of the Round Tables page.

Not all of the Web Round Tables enjoyed the same degree of success, even though great efforts were made by the chairmen and the Scientific Committee to involve as many people as possible and to stimulate discussion several months before the congress. One of the limits of this experience was the overall low participation rate with respect to the number of professionals contacted, which was probably due to the fact that the online initiative was launched too far ahead of the actual event. Nonetheless, attendance levels proved a valuable indicator of what people were interested in and helped us to choose cutting-edge topics for the approaching IGCC in Verona. For example, following the highly successful Round Table on follow-up, Chairman Luca Baiocchi put forward a proposal to the Scientific Committee for a consensus conference involving 50 experts from five continents. The project was approved and an agreement, The Charter Scaligero on Gastric Cancer, was presented and signed during the congress.

The need to pre-register for the event, not only to actively participate in the discussions but also to simply view the ongoing debates, was also considered a drawback. However, these problems could easily be resolved if it were decided to re-propose the initiative for a future congress.

The challenge of sharing the information obtained from the Web Round Table debates, discussions and experiences with the scientific community attending the actual congress was met by scheduling an event after each afternoon poster session during which an overview of the daily sessions, the best posters and the Web Round Table experience were presented in an informal atmosphere. Congress attendees had the opportunity to view, via monitor, a sort of congress take-home message in the form of the conclusions drawn in each congress session.

Conclusion

In conclusion, our fundamental aim as organizers of the 2013 IGCA congress was to further increase participation and promote greater discussion during the event. The Web Round Table initiative was successful in this respect, connecting people, ideas and resources before the event, providing the opportunity for more active involvement during the congress and leaving attendees with a feeling of having personally taken part in an enriching scientific experience.