Efficacy of adjuvant chemotherapy after curative resection for gastric cancer: a meta-analysis of published randomised trials. A study of the GISCAD (Gruppo Italiano per lo Studio dei Carcinomi dell'Apparato Digerente)

Adjuvant chemotherapy in completely resected gastric cancer: a randomized phase III trial conducted by GOIRC

BACKGROUND

Complete surgical resection of gastric cancer is potentially curative, but long-term survival is poor.

METHODS

Patients with histologically proven adenocarcinoma of the stomach of stages IB, II, IIIA and B, or IV (T4N2M0) and treated with potentially curative surgery were randomly assigned to follow-up alone or to intravenous treatment with four cycles (repeated every 21 days) of PELF (cisplatin [40 mg/m(2), on days 1 and 5], epirubicin [30 mg/m(2), days 1 and 5], L-leucovorin [100 mg/m(2), days 1-4], and 5-fluorouracil [300 mg/m(2), days 1-4] in a hospital setting. Frequencies and severity of adverse events were determined. Overall survival (OS) and disease-free survival (DFS) were compared between the treatment arms using Kaplan-Meier analysis and a Cox proportional hazards regression model. All statistical tests were two-sided.

RESULTS

From January 1995 through September 2000, 258 patients were randomly assigned to chemotherapy (n = 130) or surgery alone (n = 128). Patient characteristics were well balanced between the two arms. Among those who received chemotherapy, grade 3 or 4 toxic effects including vomiting, mucositis, and diarrhea were experienced by 21.1%, 8.4%, and 11.8% of patients, respectively. Leucopenia, anemia, and thrombocytopenia of grade 3 or 4 were experienced by 20.3%, 3.3%, and 4.2% of patients, respectively. After a median follow-up of 72.8 months, 128 patients (49.6%) experienced recurrence and 139 (53.9%) deaths were observed, one toxicity-related. Relative to treatment with surgery alone, adjuvant chemotherapy did not increase disease-free survival (hazard ratio [HR] of recurrence = 0.92; 95% confidence interval [CI] = 0.66 to 1.27) or overall survival (HR of death = 0.90; 95% CI = 0.64 to 1.26).

CONCLUSIONS

Our results failed to provide proof of an effect of adjuvant chemotherapy with PELF on overall survival or disease-free survival. The estimated effect of chemotherapy (10% reduction in the hazard of death or relapse) is modest and consistent with the results of meta-analyses of adjuvant chemotherapy without platinum agents.

Pharmacotherapy for oesophagogastric cancer

Gastric cancer is the seventh and oesophageal cancer the ninth most common cancer in the UK, and >50% of patients present with locally advanced or metastatic disease. The incidence of oesophageal and oesophagogastric junctional tumours is increasing, making these important disease entities to understand and research. Despite improvements in surgical and peri-operative supportive care, 3-year overall survival with surgery alone for resectable disease is still poor. Outcomes in localised oesophageal cancer are improved with pre-operative chemotherapy, and in gastric cancer with peri-operative treatment or post-operative chemoradiotherapy. Oesophageal squamous cell carcinoma can be treated with definitive chemoradiotherapy as an alternative to surgery. While survival in patients presenting with metastatic disease is improved with the addition of systemic chemotherapy, median survival remains <1 year. Patients who are otherwise fit can be offered chemotherapy and this is superior to best supportive care. Regimens including a platinum and an anthracycline agent are favoured by the results of randomised trials. No standard second-line therapy has emerged. New research into taxanes has shown promising anti-cancer activity, and novel areas of investigation include incorporation of agents targeting vascular endothelial growth factor or epidermal growth factor receptor into standard regimens. This review focuses on the clinical trial evidence that dictates the optimal management of localised and advanced oesophagogastric cancer, focusing on pharmacotherapy. We examine areas of current research and highlight future therapeutic directions.

Adjuvant and neoadjuvant approaches in gastric cancer

Despite the recent decline in the incidence of gastric cancer in North America and Western Europe, treatment remains a challenging problem for oncologists. Surgery is the primary modality for managing early-stage disease, but most patients who undergo a curative resection develop locoregional or distant recurrence. Consequently, there has been great interest in evaluating strategies to prevent recurrences and improve overall mortality. This article is a review of data on adjuvant and neoadjuvant treatment approaches for gastric cancer, including radiotherapy, chemotherapy, and chemoradiotherapy. Compared with surgery alone, the North American Intergroup 0116 trial demonstrated a clear survival benefit with the administration of a postoperative regimen of 5-fluorouracil, leucovorin, and external beam radiation therapy, and these findings have made concurrent chemoradiation a standard of care in patients with resected gastric cancer. More recently, the British Medical Research Council Adjuvant Gastric Cancer Infusional Chemotherapy (MAGIC) study found that preoperative and postoperative administration of epirubicin, cisplatin, and 5-fluorouracil significantly improved survival beyond surgery alone. Thus, after decades of negative studies, 2 successful strategies in localized gastric cancer are now available. Ongoing and proposed trials include the current Intergroup study (Cancer and Leukemia Group B 80101), which is assessing the role of a potentially more active postoperative chemoradiation regimen. The proposed MAGIC-B study will examine the role of adding bevacizumab to perioperative chemotherapy, and the planned CRITICS study by the Dutch Gastric Cancer Group will evaluate the role of postoperative chemoradiation in combination with preoperative chemotherapy.

Adjuvant chemotherapy of gastric cancer: which regimens?

Gastric cancer is still a major health problem and a leading cause of cancer mortality despite a worldwide decline in incidence. Surgical resection with curative potential is the only treatment modality of scientific proven effectiveness. Many phase III trials of adjuvant therapy have been conducted, however, postoperative treatment modalities have not proven to be superior to pos-surgical observation alone. Therefore, at present the routine use of adjuvant therapy should be regarded as an investigational approach. Improved clinical trial designs with standardized surgical techniques and the incorporation of newer active drugs are needed.

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

BACKGROUND

This prospective randomized study compared the survival of patients with tumour node metastasis (TNM) stage T2 N1-2 gastric cancer treated by gastrectomy alone or gastrectomy followed by uracil-tegafur.

METHODS

Patients were randomly assigned to surgery alone or to surgery and postoperative uracil-tegafur 360 mg per m(2) per day orally for 16 months. The primary endpoint was overall survival. Relapse-free survival and site of recurrence were secondary endpoints.

RESULTS

Of 190 registered patients, 95 were randomized to each group; two patients with early cancer were subsequently excluded from the chemotherapy group. The trial was terminated before the target number of patients was reached because accrual was slower than expected. Drug-related adverse effects were mild, with no treatment-related deaths. At a median follow-up of 6.2 years, overall and relapse-free survival rates were significantly higher in the chemotherapy group (hazard ratio for overall survival 0.48, P = 0.017; hazard ratio for relapse-free survival 0.44, P = 0.005), confirming the survival benefit shown in an interim analysis performed 2 years earlier.

CONCLUSION

Interim and final analyses revealed a significant survival benefit for postoperative adjuvant chemotherapy with uracil-tegafur in patients with serosa-negative, node-positive gastric cancer.

REGISTRATION NUMBER

NCT00152243 (http://www.clinicaltrials.gov).

Pharmacogenetics and stomach cancer: an update

Although new drugs and association regimens have been used in recent years, the chemotherapeutic outcome for gastric cancer is still poor and improvement in patient survival is not satisfactory. Pharmacogenetics could represent a useful approach to optimize chemotherapeutic treatments in order to identify individuals that are true candidates for clinical benefits from therapy, avoiding the development of severe side effects. The most recent update regarding gastric cancer pharmacogenetics highlights a prominent role of genetic polymorphisms of thymidylate synthase and glutathione S-transferase in the pharmacological treatment with commonly used drugs, such as 5-fluorouracil and platinum derivatives. In order to validate the genetic markers, further larger scale and controlled studies are required. A future challenge is represented by the introduction of targeted therapy in gastric cancer treatment, with the potential emerging tool of pharmacogenetic impact on this field.

The multidisciplinary management of gastrointestinal cancer. Multimodal treatment of gastric cancer

Although radical surgical R0 resections are the basis of cure for gastric cancer, surgery alone only provides long-term survival in 20-30% of patients with advanced-stage disease. Thus, in Western and European countries, advanced gastric cancer has a high risk of recurrence and metachronous metastases. Very recently, multimodal strategies combining different neoadjuvant and/or adjuvant protocols have improved the prognosis of gastric cancer when combined with surgery with curative intent. As used in palliative regimens, the combination of cisplatin with intravenous or oral fluoropyrimidines has been the integral component of such (neo)adjuvant strategies. However, the cytotoxic agents docetaxel, oxaliplatin and irinotecan and new targeted biologicals such as cetuximab, bevacizumab or panitumumab are currently under investigation, with or without irradiation, in multimodal treatment regimens. These studies may further increase R0 resection rates, and prolong disease-free and overall survival times in the treatment of advanced gastric cancer. This article reviews the most relevant literature on multimodal treatment of gastric cancer, and discusses future strategies to improve locoregional failures.

Stage-specific effect of adjuvant therapy following gastric cancer resection: a population-based analysis of 4,041 patients

BACKGROUND

Adjuvant chemoradiotherapy improved survival in patients with resected gastric adenocarcinoma in the Southwest Oncology Group/Intergroup 0116 trial. Our objective was to examine the impact of adjuvant treatment on overall survival (OS) in the general population.

METHODS

Patients 18-85 years old who had undergone resection of non-metastatic gastric adenocarcinoma between May 2000 and December 2003, were identified from the Surveillance Epidemiology and End Results (SEER) database. Patients who had received pre-operative irradiation, had unknown stage or radiation status, or had a survival of 3 months or less from the date of diagnosis were excluded. Survival of those who received post-operative irradiation was compared with those who did not; Kaplan-Meier methods and Cox proportional hazards models were used.

RESULTS

Of 4,041 patients, there was improved survival for those receiving adjuvant irradiation for stages III and IVM0, with a median OS of 31 versus 24 months (P = 0.005) and 20 versus 15 months (P < 0.001), respectively, and a trend for improved survival in univariate analysis of stage II (P = 0.0535). In final adjusted analysis, adjuvant irradiation significantly improved OS in stages III (HR: 0.71, P = 0.0007) and IVM0 (HR: 0.66, P < 0.0001). Adjusted analysis using a propensity score suggested that the benefit of adjuvant irradiation was similar in stage-II and -III patients. However, there was no statistical improvement in survival for stage-Ib and -II patients who had received adjuvant irradiation.

CONCLUSIONS

In this population-based analysis, adjuvant radiotherapy for stage-III and IVM0 gastric cancer significantly improved OS. Analysis of stage-Ib and -II patients is limited by small numbers, but there may not be the same benefit.

Management of gastric adenocarcinoma

Gastric adenocarcinoma is the second most common cause of cancer death worldwide. The prognosis for patients with gastric adenocarcinoma depends on the stage of the disease at the time of diagnosis and treatment. Early gastric cancer, limited to the mucosa and submucosa, is best treated surgically and has a five-year survival rate of 70-95%. Surgical resection remains the primary curative treatment for localised disease. Despite this, the overall survival remains poor. The management of localised gastric adenocarcinoma is complex, and at present there is proven benefit of both preoperative chemotherapy and postoperative chemoradiotherapy. There is no standard regimen of chemotherapy for metastatic disease, although the regimen of ECF (epirubicin, cisplatin and fluorouracil) is the most used regimen, with a median survival of 7-9 months. With new regimens of chemotherapy, such as DCF (docetaxel, cisplatin and fluorouracil) or the combination of irinotecan, cisplatin and bevacizumab, the median survival has increased. Other new agents are under investigation.

Adjuvant chemotherapy for gastric cancer with S-1, an oral fluoropyrimidine

BACKGROUND

Advanced gastric cancer can respond to S-1, an oral fluoropyrimidine. We tested S-1 as adjuvant chemotherapy in patients with curatively resected gastric cancer.

METHODS

Patients in Japan with stage II or III gastric cancer who underwent gastrectomy with extended (D2) lymph-node dissection were randomly assigned to undergo surgery followed by adjuvant therapy with S-1 or to undergo surgery only. In the S-1 group, administration of S-1 was started within 6 weeks after surgery and continued for 1 year. The treatment regimen consisted of 6-week cycles in which, in principle, 80 mg of oral S-1 per square meter of body-surface area per day was given for 4 weeks and no chemotherapy was given for the following 2 weeks. The primary end point was overall survival.

RESULTS

We randomly assigned 529 patients to the S-1 group and 530 patients to the surgery-only group between October 2001 and December 2004. The trial was stopped on the recommendation of the independent data and safety monitoring committee, because the first interim analysis, performed 1 year after enrollment was completed, showed that the S-1 group had a higher rate of overall survival than the surgery-only group (P=0.002). Analysis of follow-up data showed that the 3-year overall survival rate was 80.1% in the S-1 group and 70.1% in the surgery-only group. The hazard ratio for death in the S-1 group, as compared with the surgery-only group, was 0.68 (95% confidence interval, 0.52 to 0.87; P=0.003). Adverse events of grade 3 or grade 4 (defined according to the Common Toxicity Criteria of the National Cancer Institute) that were relatively common in the S-1 group were anorexia (6.0%), nausea (3.7%), and diarrhea (3.1%).

CONCLUSIONS

S-1 is an effective adjuvant treatment for East Asian patients who have undergone a D2 dissection for locally advanced gastric cancer. (ClinicalTrials.gov number, NCT00152217 [ClinicalTrials.gov].).

The impact of radiotherapy on survival in resectable gastric carcinoma: a meta-analysis of literature data

BACKGROUND

The benefit of external radiotherapy for gastric carcinoma has been extensively studied, but data on survival are still equivocal.

OBJECTIVE

To assess the effectiveness of surgery combined with preoperative radiotherapy or postoperative chemoradiotherapy in the reduction of all-cause mortality in patients with resectable gastric carcinoma.

METHODS

Computerised bibliographic searches of MEDLINE and CANCERLIT (1970-2006) were supplemented with hand searches of reference lists.

STUDY SELECTION

Studies were included if they were randomised controlled trials (RCTs) comparing mortality of surgery combined with preoperative radiotherapy or postoperative chemoradiotherapy to surgery alone, and if they included patients with histologically-proven gastric adenocarcinoma without metastases. Nine eligible RCTs, 4 of preoperative radiotherapy (832 patients) and 5 of postoperative chemoradiotherapy (869 patients), were identified and included in the meta-analysis.

DATA EXTRACTION

Data on study populations, interventions, and outcomes were extracted from each RCT according to the intention to treat method by three independent observers and combined using the DerSimonian and Laird method.

RESULTS

Surgery combined with preoperative radiotherapy compared to surgery alone significantly reduced the 3-year (OR 0.57; 95% CI 0.43-0.76: p=0.0001) and 5-year (OR 0.62; 95% CI 0.46-0.84; p=0.002) mortality rate. A significant reduction of the 5-year (OR 0.45; 95% CI 0.32-0.64; p<0.00001) mortality rate was observed when surgery followed by chemoradiotherapy was compared to surgery alone.

CONCLUSIONS

In patients with resectable gastric carcinoma, adjuvant radiotherapy significantly reduces 3-year and 5-year all-cause mortality, but the magnitude of the benefit is relatively small. Available evidence is inadequate to determine whether postoperative chemoradiotherapy is superior to preoperative radiotherapy.

UFT (tegafur and uracil) as postoperative adjuvant chemotherapy for solid tumors (carcinoma of the lung, stomach, colon/rectum, and breast): clinical evidence, mechanism of action, and future direction

UFT (tegafur and uracil) is an oral anticancer drug that has been developed in Japan. Owing to its mild toxicity profile, UFT can be suitable in an adjuvant setting following a complete tumor resection, whereas its direct antitumor effect achieved may be insufficient for advanced unresectable disease. Therefore, a variety of adjuvant chemotherapy trials with UFT have been conducted, and results of well-designed randomized controlled trials have recently shown a survival benefit of postoperative UFT treatment in resected lung, gastric, colorectal, and breast cancer. In the present article, postoperative adjuvant trials with UFT-containing chemotherapy are reviewed, and the mechanism of action and future directions are also discussed.

Postoperative chemoradiotherapy in gastric cancer -- a Phase I/II dose-finding study of radiotherapy with dose escalation of cisplatin and capecitabine chemotherapy

We hypothesised that gastric cancer outcome could be improved with more effective and intensified postoperative chemoradiotherapy. This phase I/II study was performed to determine the maximal tolerated dose (MTD) and toxicity profile of postoperative radiotherapy with concurrent daily cisplatin and capecitabine. Patients were treated with capecitabine 1000 mg m⁻² twice a day (b.i.d.) for 2 weeks. Subsequently, patients received capecitabine (250–650 mg m⁻² orally b.i.d., 5 days week⁻¹) and cisplatin (3–6 mg m⁻² i.v., 5 days week⁻¹) according to an alternating dose-escalation schedule. Radiotherapy was given to a total dose of 45 Gy in 25 fractions. Thirty-one patients completed treatment. During chemoradiotherapy, eight patients developed nine items of grade III and one episode of grade IV (mainly haematological) toxicity. The MTD was determined to be cisplatin 5 mg m⁻² i.v. and capecitabine 650 mg m⁻² b.i.d. orally. This phase I/II study demonstrated that chemoradiotherapy with daily cisplatin and capecitabine is feasible in postoperative gastric cancer at the defined dose level and is currently being tested in a phase III multicenter study.

Neoadjuvant treatment in upper gastrointestinal adenocarcinomas: new paradigms from old concepts?

PURPOSE OF REVIEW

Despite a decline in the incidence of upper gastrointestinal adenocarcinomas in North America and western Europe during the past century, treatment remains a challenging problem for oncologists. The poor outcome associated with surgical resection with curative intent has generated intensive investigation of combined modality treatment approaches including systemic chemotherapy to prevent recurrences and improve overall mortality. This article reviews data on neoadjuvant and perioperative treatment modalities for upper gastrointestinal adenocarcinomas.

RECENT FINDINGS

Postoperative chemoradiation is favored in the USA for good performance status patients with resected, high-risk gastric or gastroesophageal junction carcinoma (more stage IA). More recently, the UK Medical Research Council Adjuvant Gastric Infusional Chemotherapy (MAGIC) and Fédération Nationale des Centres de Lutte Contre le Cancer-Fédération Francophone de Cancérologie Digestive trials results, showing survival benefit with perioperative chemotherapy in operable gastric and lower esophageal cancers, have had an impact on the treatment practice in Europe.

SUMMARY

Novel strategies, involving induction with chemotherapy followed by preoperative chemoradiation, addition of targeted therapies to perioperative chemotherapy or use of new cytotoxic regimens are under evaluation to improve current standards and try to tailor therapeutic strategies.

Advances in the treatment of patients with gastric adenocarcinoma

Despite a decline in its incidence in the Western world, gastric cancer (GC) remains the fourth most frequent cancer diagnosis worldwide and is, after lung cancer, the second leading cause of death from a malignant disease globally. Based on the published literature, treatment guidelines and reports from international meetings, we here review the current treatment options for GC and discuss insights and perspectives from the latest clinical studies. The management of GC in the early stages of the disease is based on an optimal surgical resection of the primary tumor and the regional lymph nodes. However, less than one third of patients have a resectable disease at diagnosis and among those operated, more than half are not cured by surgery alone, due to a high rate of relapse. Thus, for the majority of patients, systemic cytotoxic therapy, and sometimes radiotherapy, is a treatment option both as an adjunct to surgery and in the palliative setting. Adjuvant chemotherapy offers only a marginal benefit and has not become a standard of care in the West. In North America, adjuvant chemoradiation is broadly used, shown to significantly improve overall survival, albeit with the cost of high toxicity. Furthermore, a recently reported study from the United Kingdom demonstrated a significant disease-free and survival benefit by the use of perioperative combination chemotherapy. Several chemotherapeutic agents have been tested as a palliative therapy in advanced GC including 5- fluorouracil (5-FU), oral pyrimidines, platinum derivatives, anthracyclines, taxanes and camptothecans. It is now accepted that chemotherapy is better than best supportive care only and that 5-FU based combinations are more effective than monotherapy. However, the response rates have generally been moderate and there is no consensus on the optimal combination of cytotoxic agents and the potential role of more recently developed "targeted therapies".

Results of adjuvant radiochemotherapy for gastric adenocarcinoma in Slovenia

AIMS

To analyze the results of postoperative concomitant radiochemotherapy with 5-florouracil (5-FU) and leucovorin (LV) in patients with gastric carcinoma treated in a single institution.

METHODS

During 2001-2004, 123 patients with the mean age of 60 years, were treated for adenocarcinoma of the stomach, stage Ib-IV, with postoperative concomitant radiochemotherapy. Radical (R0) and non-radical (R1) resection of the tumor was performed in 107 and 16 patients, respectively. Adjuvant treatment consisted of five cycles of five-day chemotherapy with 5-FU (425 mg/m(2)) and LV (20 mg/m(2)) and concomitant radiotherapy with the total dose of 45 Gy.

RESULTS

The treatment was completed according to the protocol in 101 patients. Stomatitis, dysphagia, and nausea and vomiting of grade three occurred in 32, 27, and 23 patients, respectively. The median follow-up time of 87 survivors was 30.4 months (range 17.4-58.3 months). At two years, locoregional control (LRC), disease-free survival (DFS), disease-specific survival (DSS) and overall survival (OS) rates were 86%, 65%, 74%, and 73%, respectively. In the multivariate analysis, the initial Hb level was identified as independent prognostic factor for all survival four endpoints, the involvement of whole stomach with cancer for LRC, the total dose of 5-FU per five-day cycle for DFS, and pT stage for DSS.

CONCLUSIONS

In operable gastric carcinoma, postoperative concomitant radiochemotherapy with 5-FU and LV is feasible and its toxicity acceptable. Its potential to improve the treatment outcome compared to the surgery alone is yet to be tested in well designed prospective randomized studies.

Adjuvant therapy for resected gastric cancer--rapid, yet incomplete adoption following results of intergroup 0116 trial

PURPOSE

The Southwest Oncology Group/Intergroup 0116 (INT-0116) trial showed that adjuvant chemoradiotherapy improves survival in high-risk gastric adenocarcinoma patients. This study examined the adoption of adjuvant treatment following the trial results and the factors associated with its use.

METHODS AND MATERIALS

Between 1996 and 2003, patients aged 18-85 years with resected gastric adenocarcinoma were identified in the Surveillance, Epidemiology, and End Results (SEER) database and classified as diagnosed before (January 1996 to April 2000) or after (May 2000 to December 2003) presentation of the INT-0116 trial findings. Univariate and multivariable models were used to determine the factors associated with use of adjuvant radiotherapy (RT).

RESULTS

Of 10,230 patients studied, 14.6% were given adjuvant RT before the INT-0116 trial, increasing to 30.4% afterward (p<0.001). Significant increases in adjuvant RT from before to after INT-0116 were seen in all demographic categories. Younger patients were significantly more likely to receive adjuvant RT (44.5%, 18-59 years; 31.0%, 60-74 years; and 12.6%, 75-85 years, p<0.0001). Married patients were significantly more likely to receive adjuvant RT (30.9%) than were unmarried patients (23.6%, p<0.001). A greater depth of tumor invasion, worse nodal status, and more lymph nodes assessed were associated with adjuvant RT (p<0.0001). The rate of adjuvant RT varied from 22.9-44.2% across SEER regions. On multiple logistic regression analysis, age, SEER region, marital status, assessed lymph nodes, tumor depth, and nodal status were all significant independent predictors of the use of adjuvant RT.

CONCLUSION

Use of adjuvant RT doubled after the INT-0116 trial results became public; however, the fraction of patients receiving adjuvant RT is still low. Additional examination of the statistically significant and clinically relevant variability between different SEER regions, tumor characteristics, and patient demographics is warranted.

Feasibility of Sequential Therapy with FOLFIRI Followed by Docetaxel/Cisplatin in Patients with Radically Resected Gastric Adenocarcinoma

OBJECTIVE

Combination therapies of fluorouracil (FU) with irinotecan (CPT-11) and docetaxel plus cisplatin have been proven to be active in metastatic gastric cancer. In this paper, we present the results of a phase III trial in which these two combinations given sequentially were compared to mitomycin C (MMC) monochemotherapy in an adjuvant setting.

METHODS

169 patients with radically resected gastric cancer were randomized to receive CPT-11 (180 mg/m2 day 1), leucovorin (100 mg/m2 days 1-2), FU (400-600 mg/m2 days 1-2, q 14; for four cycles; FOLFIRI regimen), followed by docetaxel (85 mg/m2 day 1), cisplatin (75 mg/m2 day 1, q 21; for three cycles; arm A), or MMC (8 mg/m2 days 1-2 as 2-hour infusion, q 42; for four cycles; arm B). All patients had histologically confirmed gastric carcinoma with nodal positivity or pT3/4. A total of 166 patients (85 in arm A and 81 in arm B) were treated. Adjuvant treatment was completed in 76% of the patients in arm A and in 70% of the patients in arm B. The main grade 3/4 side effects recorded were neutropenia in 35%, with only 1 febrile patient, and diarrhea in 11% in arm A, and thrombocytopenia in 10% and neutropenia in 7% in arm B. The FOLFIRI regimen and docetaxel/cisplatin given in sequence was well tolerated and feasible in adjuvant setting. This sequence treatment currently represents the experimental arm of an ongoing multicenter trial.

A phase I-II study of postoperative capecitabine-based chemoradiotherapy in gastric cancer

BACKGROUND

The Intergroup 0116 randomized study showed that postoperative 5-fluorouracil-based chemoradiotherapy improved locoregional control and overall survival in patients with gastric cancer. We hypothesized that these results could be improved further by using a more effective, intensified, and convenient chemotherapy schedule. Therefore, this Phase I-II dose-escalation study was performed to determine the maximal tolerated dose and toxicity profile of postoperative radiotherapy combined with concurrent capecitabine.

PATIENTS AND METHODS

After recovery from surgery for adenocarcinoma of the gastroesophageal junction or stomach, all patients were treated with capecitabine monotherapy, 1,000 mg/m2 twice daily for 2 weeks. After a 1-week treatment-free interval, patients received capecitabine (650-1,000 mg/m2 orally twice daily 5 days/week) in a dose-escalation schedule combined with radiotherapy on weekdays for 5 weeks. Radiotherapy was delivered to a total dose of 45 Gy in 25 fractions to the gastric bed, anastomoses, and regional lymph nodes.

RESULTS

Sixty-six patients were treated accordingly. Two patients went off study before or shortly after the start of chemoradiotherapy because of progressive disease. Therefore, 64 patients completed treatment as planned. During the chemoradiotherapy phase, 4 patients developed four items of Grade III dose-limiting toxicity (3 patients in Dose Level II and 1 patient in Dose Level IV). The predefined highest dose of capecitabine, 1,000 mg/m2 twice daily orally, was tolerated well and, therefore, considered safe for further clinical evaluation.

CONCLUSIONS

This Phase I-II study shows that intensified chemoradiotherapy with daily capecitabine is feasible in postoperative patients with gastroesophageal junction and gastric cancer.

Adjuvant chemotherapy with epirubicin, leucovorin, 5-fluorouracil and etoposide regimen in resected gastric cancer patients: a randomized phase III trial by the Gruppo Oncologico Italia Meridionale (GOIM 9602 Study)

BACKGROUND

This randomized, multicenter, phase III trial evaluated the efficacy and safety of the combination of epirubicin, leucovorin, 5-fluorouracil and etoposide (ELFE regimen) as adjuvant therapy for radically resected gastric cancer patients.

PATIENTS AND METHODS

From June 1996 to June 2001, 228 stage IB-IIIB gastric cancer patients were enrolled. All patients received a total or subtotal gastrectomy with at least a D1 lymphoadenectomy and were randomly assigned to receive surgery alone or surgery followed by chemotherapy.

RESULTS

A total number of 630 cycles was delivered with a median number of 5. With a median follow-up of 60 months, the 5-year overall survival (OS) was 48% in the treatment arm and 43.5% in the control arm [hazard ratio (HR) 0.91; 95% confidence interval (CI) 0.69-1.21; P = 0.610); the 5-year disease-free survival (DFS) was 44% in the treatment arm and 39% in the control arm (HR 0.88; 95% CI 0.78-0.91; P = 0.305). In node-positive patients, the 5-year OS was 41% in the treatment arm and 34% in the control arm (HR 0.84; 95% CI 0.69-1.01; P = 0.068), while the 5-year DFS was 39% in the treatment arm and 31% in the control arm (HR 0.88; 95% CI 0.78-0.91; P = 0.051). The most common grade 3-4 toxic effects according to World Health Organization criteria were hematological and gastrointestinal.

CONCLUSIONS

In radically resected gastric cancer patients, adjuvant chemotherapy with ELFE regimen does not improve OS over surgery alone.

Neo-adjuvant and adjuvant chemotherapy of gastric cancer

Gastric cancer is still a major health problem and a leading cause of cancer mortality despite a worldwide decline in incidence. Surgery is the primary curative treatment of locoregional gastric cancer. In Western countries, however, at the time of resection, most patients are expected to have regional lymph node involvement with poor prognostic implications. To improve these results, different trials have been carried out in the adjuvant or neo-adjuvant setting. Many phase III trials of adjuvant therapy have been conducted; however, postoperative treatment modalities have not proven to be superior to postsurgical observation alone. Therefore, at present the routine use of adjuvant therapy should be regarded as an investigational approach. Improved clinical trial designs with standardized surgical techniques and the incorporation of newer active drugs are needed. On the contrary, neo-adjuvant chemotherapy has shown promising results as suggested by the final results of UK Medical Research Council Adjuvant Gastric Infusional Chemotherapy trial.

Adjuvant chemoradiation for gastric cancer: experience in the Chinese population

AIMS

The role of adjuvant chemoradiation for gastric cancer after curative R0 gastrectomy was first established by the US Intergroup 0116 study. Although confirmatory studies are in progress, few data are available regarding its application to the Chinese population. We describe our radiotherapy technique and report the treatment results in Hong Kong.

MATERIALS AND METHODS

This was a single centre retrospective study on 63 Chinese patients who underwent adjuvant chemoradiation for gastric adenocarcinoma between June 2000 and December 2004. The treatment protocol was based on that of the Intergroup study. Computed tomography planned anteroposterior opposing field arrangement and treatment under breath hold at deep inspiration position were adopted.

RESULTS

In total, 63 patients, mean age 50 years, with gastric cancer stage IB to limited metastatic IV disease were analysed. The median follow-up time was 27.2 months. The relapse-free survival and overall survival at 3 years were 50 and 54%, respectively. The recurrence pattern was dominated by distant failure and only one patient developed isolated locoregional recurrence. Of the 10 patients who had positive microscopic surgical margins after surgery, seven had recurred and died. On multivariate analysis, margin status was the only significant prognosticator for survival. Thirty per cent of patients experienced grade 3 or above acute toxicity (24% haematological, 14% gastrointestinal) and one patient died of neutropenic sepsis. There was one case of grade 3 late toxicity.

CONCLUSIONS

The outcome after adjuvant chemoradiation for gastric cancer seemed to be favourable, with manageable toxicities, in the Chinese population. Locoregional failure was uncommon. Patients with microscopic surgical margin involvement had a very high failure rate despite adjuvant chemoradiation.

5-fluorouracil, mitomycin-C, and polysaccharide-K adjuvant chemoimmunotherapy for locally advanced gastric cancer: the prognostic significance of frequent perineural invasion

BACKGROUND/AIMS

Although adjuvant chemotherapy has demonstrated small but significant survival benefit in locally advanced gastric cancer in several meta-analyses, optimal chemotherapy regimen remains to be determined.

METHODOLOGY

We retrospectively analyzed the survival of 207 gastric cancer patients (stage IB: 19, II: 65, IIIA: 58, IIIB: 28, IV: 37) who underwent 5-fluorouracil (5-FU), mitomycin-C (MMC), and polysaccharide-K (PSK) chemoimmunotherapy (CITX) after curative resection (FM group). The survival of FM group was compared with that of historical control cohort of 103 patients with almost identical stage distribution who received 5-FU and doxorubicin-based chemotherapy (FA group).

RESULTS

Five-year disease-free survival and overall survival (OS) of FM group were 58.7% and 59.1%, respectively. Frequent perineural invasion was significantly associated with poor OS (p = 0.01) in multivariate analysis. There was no statistically significant difference in 5-year OS (59.1% vs. 56.2%, p = 0.637) between FM and FA groups. FM group showed superior 5-year OS (84.4% vs. 67.6%, p = 0.019) compared with FA group in stage IB or II patients without significant difference (p = 0.222) in stage IIIA to IV.

CONCLUSIONS

5-FU, MMC, and PSK CITX is as effective as 5-FU and doxorubicin-based chemotherapy. Moreover, frequent perineural invasion seems to be an important poor prognostic factor.

Adjuvant treatment of high-risk, radically resected gastric cancer patients with 5-fluorouracil, leucovorin, cisplatin, and epidoxorubicin in a randomized controlled trial

BACKGROUND

Promising findings obtained using a weekly regimen of 5-fluorouracil (5-FU), epidoxorubicin, leucovorin (LV), and cisplatin (PELFw) to treat locally advanced and metastatic gastric cancer prompted the Italian Group for the Study of Digestive Tract Cancer (GISCAD) to investigate the efficacy of this regimen as adjuvant treatment for high-risk radically resected gastric cancer patients.

METHODS

From January 1998 to January 2003, 400 gastric cancer patients at high risk for recurrence including patients with serosal invasion (stage pT3 N0) and/or lymph node metastasis (stage pT2 or pT3 N1, N2, or N3), were enrolled in a trial of adjuvant chemotherapies; 201 patients were randomly assigned to receive the PELFw regimen, consisting of eight weekly administrations of cisplatin (40 mg/m2), LV (250 mg/m2), epidoxorubicin (35 mg/m2), 5-FU (500 mg/m2), and glutathione (1.5 g/m2) with the support of filgrastim, and 196 patients were assigned to a regimen consisting of six monthly administrations of a 5-day course of 5-FU (375 mg/m2 daily) and LV (20 mg/m2 daily, 5-FU/LV). Disease-free and overall survival were estimated and compared between arms using hazard ratios (HRs) and Kaplan-Meier estimates. All statistical tests were two-sided.

RESULTS

The 5-year survival rates were 52% in the PELFw arm and 50% in the 5-FU/LV arm. Compared with the 5-FU/LV regimen, the PELFw regimen did not reduce the risk of death (HR = 0.95, 95% confidence interval [CI] = 0.70 to 1.29) or relapse (HR = 0.98, 95% CI = 0.75 to 1.29). Less than 10% of patients in either arm experienced a grade 3 or 4 toxic episode. Neutropenia (occurring more often in the PELFw arm) and diarrhea and mucositis (more prevalent in the 5-FU/LV arm) were the most common serious side effects. Nevertheless, only 19 patients (9.4%) completed the treatment in the PELFw arm and 85 (43%) patients completed the treatment in the 5-FU/LV arm.

CONCLUSIONS

Our study found no benefit from an intensive weekly chemotherapy in gastric cancer. The extent of toxicity experienced by the patients in the adjuvant setting suggests that, in gastric cancer, chemotherapy may be more safely administered preoperatively.

Adjuvant treatment of high-risk, radically resected gastric cancer patients with 5-fluorouracil, leucovorin, cisplatin, and epidoxorubicin in a randomized controlled trial

BACKGROUND

Promising findings obtained using a weekly regimen of 5-fluorouracil (5-FU), epidoxorubicin, leucovorin (LV), and cisplatin (PELFw) to treat locally advanced and metastatic gastric cancer prompted the Italian Group for the Study of Digestive Tract Cancer (GISCAD) to investigate the efficacy of this regimen as adjuvant treatment for high-risk radically resected gastric cancer patients.

METHODS

From January 1998 to January 2003, 400 gastric cancer patients at high risk for recurrence including patients with serosal invasion (stage pT3 N0) and/or lymph node metastasis (stage pT2 or pT3 N1, N2, or N3), were enrolled in a trial of adjuvant chemotherapies; 201 patients were randomly assigned to receive the PELFw regimen, consisting of eight weekly administrations of cisplatin (40 mg/m2), LV (250 mg/m2), epidoxorubicin (35 mg/m2), 5-FU (500 mg/m2), and glutathione (1.5 g/m2) with the support of filgrastim, and 196 patients were assigned to a regimen consisting of six monthly administrations of a 5-day course of 5-FU (375 mg/m2 daily) and LV (20 mg/m2 daily, 5-FU/LV). Disease-free and overall survival were estimated and compared between arms using hazard ratios (HRs) and Kaplan-Meier estimates. All statistical tests were two-sided.

RESULTS

The 5-year survival rates were 52% in the PELFw arm and 50% in the 5-FU/LV arm. Compared with the 5-FU/LV regimen, the PELFw regimen did not reduce the risk of death (HR = 0.95, 95% confidence interval [CI] = 0.70 to 1.29) or relapse (HR = 0.98, 95% CI = 0.75 to 1.29). Less than 10% of patients in either arm experienced a grade 3 or 4 toxic episode. Neutropenia (occurring more often in the PELFw arm) and diarrhea and mucositis (more prevalent in the 5-FU/LV arm) were the most common serious side effects. Nevertheless, only 19 patients (9.4%) completed the treatment in the PELFw arm and 85 (43%) patients completed the treatment in the 5-FU/LV arm.

CONCLUSIONS

Our study found no benefit from an intensive weekly chemotherapy in gastric cancer. The extent of toxicity experienced by the patients in the adjuvant setting suggests that, in gastric cancer, chemotherapy may be more safely administered preoperatively.

Treatment results for gastric cancer surgery: 12 years' experience at a single institute in Korea

AIMS

To evaluate the changing trends of clinicopathologic features, surgical procedures and treatment outcomes of gastric cancer in a large-volume center.

METHODS

We divided the time period into two parts: the first is 1989-1996 (period I) and the second is 1997-2001 (period II). Then we analyzed prospectively collected data on 1816 patients treated at Kangnam St. Mary's Hospital, The Catholic University of Korea, from 1989 to 2001.

RESULTS

Upper one-third cancer was seen more prevalently in period II than period I (9.4% versus 6.6%) (p=0.000) and total gastrectomy was performed more frequently in period II than period I (25% versus 18%) (p=0.000). A diagnosis of early gastric cancer was made more prevalently in period II than period I (40% versus 27%) (p=0.000). D2 lymphadenectomy was done in 74% of the period I patients and 83% of their period II counterparts (p=0.000). Between the two periods, there was a significant difference in the incidence of operation-related major complications (9.9% in period I versus 3.9% in period II) (p=0.000) and the mortality (1.8% versus 0.6%) (p=0.023). The overall 5-year and 10-year survival rates were significantly higher in period II than period I (63% and 57% in period I versus 69% and 64% in period II) (p=0.009).

CONCLUSIONS

The overall survival of gastric cancer significantly increased because of the early detection and aggressive surgical approaches by experienced surgeons in a large-volume center. More effective multidisciplinary approaches are warranted to improve the prognosis of advanced gastric cancer.

Adjuvant chemoradiotherapy for gastric carcinoma: dosimetric implications of conventional gastric bed irradiation and toxicity

AIMS

Recently, a survival advantage has been shown using adjuvant chemoradiotherapy after complete resection of gastric cancer. If survival advantages are to be maintained, treatment-related complications must be minimised. In this study, we explored the dosimetric implications and toxicity of conventional large field gastric bed irradiation.

MATERIALS AND METHODS

Between 2000 and 2002, 16 patients received adjuvant 5-fluorouracil (5-FU) chemoradiotherapy after complete resection of gastric cancer. Radiotherapy was simulator planned using anterior-posterior parallel opposed fields to 45 Gy in 25 daily fractions over 5 weeks.

RESULTS

Thirteen patients (81%) completed radiotherapy and eight patients (50%) completed chemotherapy as planned. Toxicity was the main factor for discontinuation. Substantial dose inhomogeneities were shown using retrospective computed tomography recreation of dose-volume histograms (DVHs) of the organs at risk.

CONCLUSIONS

Although the delivery of chemoradiotherapy using conventional two-dimensional simulator planning is a feasible technique, significant under-appreciation of dose inhomogeneity exists. Conformal computed tomography planning is vital to document doses received by organs at risk, especially the spinal cord and kidneys, which may receive high doses, and prospectively correlate these with acute and long-term toxicity in order to redefine organ at risk tolerances in the setting of chemoradiation.

Retrospective analysis of 45 consecutive patients with advanced gastric cancer treated with neoadjuvant chemotherapy using an S-1/CDDP combination

BACKGROUND

Standard treatment for highly advanced gastric cancer (AGC) has not been established yet. Neoadjuvant chemotherapy (NAC) represents a promising approach, which may improve the prognosis of AGC. In this study, we analyzed the feasibility and efficacy of NAC with S-1 (TS-1)/cisplatin CDDP in order to design appropriate clinical trials for AGC.

METHODS

Results for a series of 45 consecutive patients with AGC treated with S-1/CDDP induction chemotherapy since January 2002 were analyzed retrospectively.

RESULTS

The primary tumor was resected in 36 of the 45 patients (resectability, 80.0%). Progression of the disease during chemotherapy was observed in 1 patient only (2.2%). No treatment-related deaths occurred, and serious adverse effects (grade 3-4) were noted in only 2.2% of the patients. The overall median survival time was 1.82 years. Especially noteworthy is that, in patients with highly advanced disease (pretreatment [c]-stage IV; n = 27), resectability was 66.7% and curative (R0) resection was possible in 10 patients. The median survival times for c-stage IV patients who had total, curative, and noncurative resections were 20.8, 22.3 and 12.6 months, respectively. R0 resection was possible for all c-stage III patients (n = 17), with a 2-year overall survival of 90.9%. The downstaging rate was 55.6% (20/36), resulting in a significantly improved prognosis for the downstaged patients (P = 0.012).

CONCLUSION

Induction chemotherapy using S-1/CDDP for AGC appears to be a safe and promising treatment. We have therefore started two independent multiinstitutional clinical trials to evaluate the efficacy of this treatment.

Chemotherapy sensitivity and resistance testing: to be "standard" or to be individualized, that is the question

Radical surgery with extended lymph-node dissection is the treatment of first choice and the only curative treatment for locally advanced gastric cancer. While recent combination chemotherapy with S-1 (a combination of tegafur with two biomodulators, gimeracil and oteracil) has achieved high response rates, controversy still remains regarding the significance of adjuvant cancer chemotherapy after surgery. We have been applying chemosensitivity testing in evaluating the appropriate adjuvant cancer chemotherapy for advanced gastric cancer. Our multiple studies have indicated that this chemosensitivity testing would be useful to improve the results of adjuvant chemotherapy, by increasing survivals in the sensitive group. The chemosensitivity testing is approved as "advanced clinical medicine" by the Japanese Ministry of Health, Welfare, and Labor at 11 institutes at present. While complete lymph-node dissection and chemosensitivity test-guided adjuvant chemotherapy has been reported to result in a survival benefit for patients with advanced gastrointestinal cancer, the clinical utility of the testing should be established by means of prospective, randomized clinical trials. Two pivotal clinical trials have been initiated to clarify the utility of chemosensitivity testing in the selection of the appropriate adjuvant cancer chemotherapy for gastric cancer.

Postoperative chemotherapy for gastric cancer

INTRODUCTION

Adjuvant chemotherapy for gastric cancer after potentially curative surgery has been under clinical investigation for more than four decades. However, potentially curative resection can be performed in only 30%-50% of patients. The objective of this article is to review briefly the clinical trials available in the current literature using adjuvant cytotoxic chemotherapy in patients with gastric cancer after potentially curative surgical resection.

METHODS

Computerized (MEDLINE) and manual searches were performed to identify papers published on this topic between 1965 and 2005. Only articles with an English abstract were reviewed for inclusion; information abstracted included histologic proof of diagnosis, number of patients, dose and modality of treatment, survival duration, and side effects.

RESULTS

Forty-three reports were identified. Single-agent chemotherapy was evaluated in four clinical trials, and postoperative combination chemotherapy was evaluated in 33 trials. Furthermore, we identified five meta-analyses. Five-year survival rates ranged from 12%-91.2%, and the median survival durations were 13-60+ months. Adjuvant chemotherapy, when compared with surgery alone, seems to result in longer survival.

CONCLUSION

The high rate of recurrence, even in patients undergoing state-of-the art curative resection, suggests that effective adjuvant chemotherapy might indeed be an attractive concept to improve the overall outcome of patients with gastric cancer. However, because there is no standard regimen for postoperative treatment at the moment, patients with R0-resected (no residual tumors) gastric cancer should be offered the opportunity to participate in prospective clinical trials.

Cancer of the Gastroesophageal Junction: Combined Modality Therapy

Esophageal cancer, an uncommon, but highly virulent malignancy in the United States, will be responsible for nearly 14,000 deaths in the year 2005. The prognosis for patients who have adenocarcinoma of the distal esophagus and gastroesophageal junction and who are treated with the standard approaches of surgery or combined chemoradiation therapy is poor. Recent clinical trials have evaluated the use of preoperative chemotherapy followed by surgery, combined concurrent preoperative chemoradiotherapy followed by surgery, or definitive chemoradiotherapy alone without surgery. This article focuses on recent advances in the use of combined modality therapy in adenocarcinoma of the esophagus and gastroesophageal junction.

Topoisomerase IIalpha gene amplification in gastric carcinomas: correlation with the HER2 gene. An immunohistochemical, immunoblotting, and multicolor fluorescence in situ hybridization study

Topoisomerase IIalpha (topoIIalpha) is an enzyme required for DNA replication and a molecular target for drugs called anthracyclines. The topoIIalpha gene (TOP2A) is located close to the HER-2/neu oncogene (HER2). We assessed gastric cancers to (1) clarify the relationship between gene amplification and protein overexpression of topoIIalpha and HER2; (2) evaluate the correlation between gene amplification and protein overexpression of topoIIalpha; and (3) examine the relationship between the results of immunohistochemistry and Western blot analysis for topoIIalpha. In a combined analysis of immunohistochemistry and fluorescence in situ hybridization on 552 formalin-fixed and paraffin-embedded gastric cancer tissues, 38 cases were found to have HER2 amplification. Further examination by fluorescence in situ hybridization revealed amplification of TOP2A in 13 of the 38 cases. No aberrations in the TOP2A gene were observed in cases without HER2 overexpression, except for one containing a gene deletion. The TopoIIalpha protein-labeling index was not correlated with TOP2A amplification. Fluorescence in situ hybridization was performed on nuclear imprint specimens obtained from 9 cases using simultaneous probes for TOP2A, HER2, and centromere 17. Of these 9 cases, 3 displayed coamplification of TOP2A and HER2, and only 1 of the 3 cases revealed a high expression of topoIIalpha in Western blot. Although patients having gastric adenocarcinoma with TOP2A amplification could be considered suitable for clinical trials, information involving anthracycline therapy is not firmly understood in regards to the status of TOP2A amplification or protein overexpression. Therefore, results of the current study will provide further insight for the clinical application of anthracycline in gastric cancers.

Endoscopic scoring of late gastrointestinal mucosal damage after adjuvant radiochemotherapy

AIM: To evaluate late effects of chemoradiation on gastrointestinal mucosa with an endoscopic scoring system and compare it to a clinical scoring system.

METHODS: Twenty-four patients going to receive chemoradiation after gastric surgery underwent endoscopy four wk after surgery and one year after the chemoradiation finished. Upper gastrointestinal findings were recorded according to a system proposed by World Organisation for Digestive Endoscopy (OMED) and clinical scoring was done with RTOG-EORTC radiation morbidity scoring systems.

RESULTS: There was no significant endoscopic difference in gastric and intestinal mucosa after chemoradiation (P > 0.05) and there was no association between endoscopic scores and clinical scores. Endoscopic changes were minimal.

CONCLUSION: Late effects after chemoradiation in operated patients with gastric cancers can be evaluated with an endoscopic scoring system objectively and this system is superior to clinical scoring systems.

Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer

BACKGROUND

A regimen of epirubicin, cisplatin, and infused fluorouracil (ECF) improves survival among patients with incurable locally advanced or metastatic gastric adenocarcinoma. We assessed whether the addition of a perioperative regimen of ECF to surgery improves outcomes among patients with potentially curable gastric cancer.

METHODS

We randomly assigned patients with resectable adenocarcinoma of the stomach, esophagogastric junction, or lower esophagus to either perioperative chemotherapy and surgery (250 patients) or surgery alone (253 patients). Chemotherapy consisted of three preoperative and three postoperative cycles of intravenous epirubicin (50 mg per square meter of body-surface area) and cisplatin (60 mg per square meter) on day 1, and a continuous intravenous infusion of fluorouracil (200 mg per square meter per day) for 21 days. The primary end point was overall survival.

RESULTS

ECF-related adverse effects were similar to those previously reported among patients with advanced gastric cancer. Rates of postoperative complications were similar in the perioperative-chemotherapy group and the surgery group (46 percent and 45 percent, respectively), as were the numbers of deaths within 30 days after surgery. The resected tumors were significantly smaller and less advanced in the perioperative-chemotherapy group. With a median follow-up of four years, 149 patients in the perioperative-chemotherapy group and 170 in the surgery group had died. As compared with the surgery group, the perioperative-chemotherapy group had a higher likelihood of overall survival (hazard ratio for death, 0.75; 95 percent confidence interval, 0.60 to 0.93; P=0.009; five-year survival rate, 36 percent vs. 23 percent) and of progression-free survival (hazard ratio for progression, 0.66; 95 percent confidence interval, 0.53 to 0.81; P<0.001).

CONCLUSIONS

In patients with operable gastric or lower esophageal adenocarcinomas, a perioperative regimen of ECF decreased tumor size and stage and significantly improved progression-free and overall survival. (Current Controlled Trials number, ISRCTN93793971 [controlled-trials.com].).

Selecting a specific pre- or postoperative adjuvant therapy for individual patients with operable gastric cancer

Although the very high locoregional recurrence rates reported with limited D0/D1 surgery can be reduced with extended D2 gastrectomy for operable gastric cancer, overall relapse and survival rates remain poor and can only be improved with adequate perioperative adjuvant treatment. However, despite intensive research, no regimen has been established as standard. Meta-analyses have demonstrated a marginal survival benefit with adjuvant chemotherapy. Two recent large randomized trials for operable gastric cancer, the MAGIC trial and the INT-0116 trial, provide evidence that some patients may benefit from perioperative chemotherapy and chemoradiation, respectively. However, while both trials suggest an overall survival benefit with adjuvant treatment, they don't provide the harm-benefit ratio for specific subsets of patients wih different extent of surgery (D1 or D2) and tumor stage (early [T1,2]/advanced [T3,4]). This lack of evidence complicates current therapeutic adjuvant decisions. Estimating the risk of local and distant recurrence (high, moderate or low) after D1 or D2 surgery in various tumor stages and the expected harm-benefit ratio, the authors provide useful information for decisions on adjuvant chemotherapy with or withour radiotherapy in individual patients. Research on newer cytotoxic and targeted agents may improve treatment efficacy. Simultaneously, advances with microarray-based gene-expression profiling signatures may improve individualized treatment decisions. However, the validation and translation of these genomic classifiers as biomarkers into a completed 'bench-to-bedside' cycle for tailoring treatment to individuals is a major challenge and limits inflated expectations.

Challenges in the treatment of gastrointestinal tumours

In the last 20 years there have been many breakthroughs in the treatment of gastrointestinal tumours. In this review we have considered the three most important subgroups of gastrointestinal tumours (colorectal, gastric and pancreatic cancer), focusing on the state-of-the-art treatments.

Chemotherapy as a component of multimodal therapy for gastric carcinoma

Prognosis of locally advanced gastric cancer remains poor, and several multimodality strategies involving surgery, chemotherapy, and radiation have been tested in clinical trials. Phase III trial testing the benefit of postoperative adjuvant chemotherapy over treatment with surgery alone have revealed little impact on survival, with the exception of some small trials in Western nations. A large trial from the United States exploring postoperative chemoradiation was the first major success in this category. Results from Japanese trials suggest that moderate chemotherapy with oral fluoropyrimidines may be effective against less-advanced (T2-stage) cancer, although another confirmative trial is needed to prove this point. Investigators have recently turned to neoadjuvant chemotherapy, and some promising results have been reported from phase II trials using active drug combinations. In 2005, a large phase III trial testing pre- and postoperative chemotherapy has proven its survival benefit for resectable gastric cancer. Since the rate of pathologic complete response is considered to affect treatment results of this strategy, neoadjuvant chemoradiation that further increases the incidence of pathologic complete response could be a breakthrough, and phase III studies testing this strategy may be warranted in the near future.

Surgical outcomes in patients with T4 gastric carcinoma

BACKGROUND

There is controversy about the best therapeutic surgical approach for treatment of patients with T4 gastric cancer.

STUDY DESIGN

We used univariate and multivariate analyses to review the surgical outcomes and prognostic factors of 117 patients who underwent surgery for T4 gastric carcinoma.

RESULTS

Curative resection was performed in 38 (32.4%) patients, with the pancreas being the most frequently resected organ. The 5-year survival rate was 16.0% and the median survival time (MST) was 11 months for all 117 registered patients. The 5-year survival rates and MSTs in patients after curative and noncurative resection were 32.2% versus 9.5% and 20 months versus 8 months, respectively. These values differed considerably between the two groups (p < 0.0001). Curability was an independent prognostic factor among all registered patients, including those who underwent noncurative resection. A relatively small tumor diameter (< 100 mm) and few lymph node metastases (six or fewer metastatic lymph nodes) were independent prognostic factors when curative resection could be performed. Postoperative morbidity and mortality were acceptable after curative combined resection.

CONCLUSIONS

We recommend the use of aggressive combined resection of adjacent organs, with extended lymph node dissection, for patients with T4 gastric carcinoma in whom curative resection can be used; that is, those with few metastatic lymph nodes (six or less) and a relatively small tumor diameter (100 mm). But noncurative resection should be avoided in patients with T4 gastric cancer.

Preoperative and adjuvant therapies for upper gastrointestinal cancers

Survival of esophageal, gastrointestinal junction and gastric cancers is poor given that they frequently present with locally advanced or metastatic disease. The incidence of gastrointestinal junction adenocarcinoma is increasing whereas that of squamous cell carcinoma of the esophagus is decreasing. The accuracy of staging has improved with newer diagnostic techniques, including positron emission tomography, endoscopic ultrasound and laparoscopy, and this should be integrated in prospective Phase III clinical trials evaluating neoadjuvant and adjuvant therapies for some esophageal and all gastric carcinomas. For esophageal cancer (except for one trial by Walsh and colleagues), four randomized Phase III trials comparing preoperative chemoradiation followed by surgery versus surgery alone have not shown a survival benefit. Neither have the trials, where preoperative chemoradiation followed by surgery, is compared with definitive chemoradiation. Nevertheless, it is commonly practiced in the USA and has become a preferred combined modality approach. Postoperative chemoradiation is favored in the USA for good performance status patients with resected, high-risk gastric or gastroesophageal junction carcinoma (more than Stage IA). The UK-MAGIC trial results, showing survival benefit with perioperative chemotherapy in operable gastric and lower esophageal cancers, probably has an impact on the treatment practice of these cancers in Europe and Asia. Promising results from trials involving preoperative chemoradiation followed by surgery in gastric cancer (pathologic complete response of 20-30%) need to be further evaluated in a Phase III setting and compared with postoperative chemoradiation. Active ongoing research will help us clarify the role of preoperative and adjuvant therapies in esophageal and gastric cancers. The role of molecular profiling is evolving and will help us differentiate the responders from the nonresponders.

Randomized phase III trials of adjuvant FAMTX or FEMTX compared with surgery alone in resected gastric cancer. A combined analysis of the EORTC GI Group and the ICCG

BACKGROUND

In patients who underwent radical resection for gastric cancer, we investigate the relative efficacy of combined 5-fluorouracil+adriamycin or epirubicin and methotrexate with leucovorin rescue (FAMTX or FEMTX) compared with a control arm.

PATIENTS AND METHODS

This report is a prospective combined analysis of two randomized clinical trials conducted on patients who underwent radical resection for histologically proven adenocarcinoma of the stomach or esophago-gastric junction. Three hundred and ninety-seven untreated patients, 206 from 23 European Organization for Research and Treatment of Cancer (EORTC) institutions and 191 from 16 International Collaborative Cancer Group (ICCG) institutions, were randomized. Overall survival (OS) and disease-free survival (DFS) were estimated using the Kaplan-Meier method and the treatments were compared for these end-points by means of the log-rank test, retrospectively stratified by trial.

RESULTS

In a planned combined analysis of the two trials, no significant differences were found between the treatment and control arms for either DFS (hazards ratio: 0.98, P=0.87) or OS (hazards ratio: 0.98, P=0.86). The 5-year OS was 43% in the treatment arm and 44% in the control arm and the 5-year DFS was 41% and 42%, respectively.

CONCLUSION

Neither FAMTX nor FEMTX can be advocated as adjuvant treatment in patients who undergo resection for gastric cancer.