Randomized controlled trial of adjuvant uracil-tegafur versus surgery alone for serosa-negative, locally advanced gastric cancer

Meta-analysis of adjuvant chemotherapy after radical surgery for advanced gastric cancer

BACKGROUND

There is no consensus of opinion about postoperative adjuvant chemotherapy after radical surgery for advanced gastric cancer. This is a meta-analysis of the published results of relevant randomized clinical trials (RCTs).

METHODS

Electronic databases from January 1998 to December 2007 were searched and 12 RCTs were selected. These included a total of 3809 patients. The hazard ratio (HR) for overall survival was calculated.

RESULTS

The pooled HR for overall survival was 0.78 (95 per cent confidence interval 0.71 to 0.85) in favour of chemotherapy. Subgroup analysis showed that the advantage of chemotherapy was not influenced by depth of tumour infiltration, status of lymph node metastasis, type of lymphadenectomy, geographical distribution of patients or route of drug administration.

CONCLUSIONS

Postoperative chemotherapy can improve overall survival after radical surgery for gastric cancer; there is no standardized chemotherapy regimen. Japanese-style D2 radical surgery plus oral 5-fluorouracil appears an effective treatment at present.

Improved local control by surgery and paclitaxel-based chemoradiation for esophageal squamous cell carcinoma: results of a retrospective non-randomized study

BACKGROUND AND OBJECTIVES

To investigate the impact of using paclitaxel in chemoradiation on locally advanced esophageal squamous cell carcinoma (SCC) treated with or without surgery.

METHODS

Of 127 patients with AJCC stages II-III esophageal SCC undergoing definitive chemoradiation (DefCRT, n = 44) or neoadjuvant chemoradiation plus surgery (NeoCRT + S, n = 83), 57 received chemotherapy with paclitaxel and cisplatin (TP), and 70 received 5-fluorouracil and cisplatin (PF). Three-year local progression-free survival (LPFS), distant metastasis-free survival, overall survival, and prognostic factors were retrospectively analyzed.

RESULTS

The median survival was 30 months. Pathological complete response rate was 41% and 27% with TP and PF, respectively (P = 0.19). NeoCRT + S achieved significantly higher LPFS than DefCRT (71% vs. 39%, P < 0.001). Patients receiving TP had significantly higher LPFS than PF (74% vs. 48%, P = 0.04). Local control was similar between DefCRT with TP and NeoCRT + S. Distant metastasis-free survival and overall survival were not different between treatment modalities or chemotherapy regimens. In multivariate analysis, surgery (HR 0.30, P < 0.001), TP regimen (HR 0.38, P = 0.007), and mediastinal lymphadenopathy (HR 2.37, P = 0.008) were independent factors for LPFS.

CONCLUSIONS

Both surgery and the use of paclitaxel-based chemoradiation may improve local disease control. Future randomized trials should integrate paclitaxel into definitive chemoradiation.

Surgery and adjuvant chemotherapy

It was clearly demonstrated that good local control by either radiotherapy or D2 surgery is essential to cure gastric cancer. D2 surgery can be carried out safely with a large volume of patients and can provide better survival than limited surgery. More extended surgery than D2 cannot provide better survival and causes greater morbidity; therefore, it should not be carried out as prophylactic lymphadenectomy. The effect of adjuvant treatment depends on the type of surgery. Neoadjuvant plus post-operative triplet chemotherapy, postoperative adjuvant chemoradiotherapy, and postoperative S-1 monotherapy now are the standards of care in Europe, the United States, and Japan, respectively.

Current strategies in systemic treatment of gastric cancer and cancer of the gastroesophageal junction

Gastric cancer is a major health issue and a leading cause of death worldwide. The results of standard therapy remain unsatisfactory mainly because of diagnosis at the late stage of disease. Innovative strategies such as neoadjuvant chemotherapy in locally advanced cancer have improved the outcome even in operable cases. Whether an adjuvant radiochemotherapy is of benefit after curative resection including systematic lymphadenectomy remains yet unclear. Some progress has been made in the palliative setting by introducing new substances. This review examines recent advances in the systemic treatment of gastric and gastroesophageal junction cancer.

The role of UFT in advanced gastric cancer

BACKGROUND

Advanced gastric cancer has a poor prognosis, with a relative 5-year survival rate of 7%-27%. Chemotherapy, which improves overall survival (OS) and quality of life, is the main treatment option. Although numerous regimens have been investigated, there is no standard treatment. Combination chemotherapy, however, is associated with a significant survival benefit compared with monotherapy and i.v. 5-fluorouracil (5-FU) is one of the most widely used agents. UFT (tegafur-uracil) has similar efficacy to continuous infusion 5-FU with improved tolerability and is more convenient for patients.

DESIGN

The efficacy and safety of UFT in the treatment of advanced gastric cancer have been demonstrated in a number of phase II studies.

RESULTS

UFT with leucovorin (folinic acid) monotherapy shows overall response rates (ORRs) of 16%-29% and median OS of 5.8 months. Combination of UFT with cisplatin, etoposide, or paclitaxel shows ORRs of 35%-51% and median OS of 8.3-10.1 months. UFT-based three-drug combinations show ORRs of 41%-57% and median OS of 8.6-15 months. UFT-based combinations have a good tolerability profile, particularly a low incidence of myelosuppression, mucositis, and hand-foot syndrome.

CONCLUSION

UFT represents a logical replacement for 5-FU in chemotherapy regimens for the treatment of advanced gastric cancer.

The role of S-1 in the treatment of gastric cancer

S-1 is a potent antitumour drug in gastric cancer. After years of disagreement about the utility of chemotherapy for advanced gastric cancer, several studies have recently demonstrated the efficacy of S-1 in both the adjuvant and primary settings. In this Minireview, the value of S-1 in the treatment of gastric cancer is discussed.