Neoadjuvant chemotherapy for gastric cancer: update

Preoperative N stage evaluation in advanced gastric cancer patients using multidetector CT: can the sum of the diameters of metastatic LNs be used for N stage evaluation?

AIM

To compare the diagnostic performance of total counts of metastatic lymph nodes (LN-sum) and conventional multidetector (MD) computed tomography (CT) staging in the nodal evaluation of advanced gastric cancer (AGC) patients.

MATERIALS AND METHODS

In total, 127 consecutive patients who underwent preoperative MDCT and gastrectomy for AGC were identified. Metastatic LNs on MDCT were defined as LNs with a short axis ≥8 mm, marked or heterogeneous enhancement, and morphological features (central necrosis, round shape, clustering). The sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of the N-stage using LN-sum and conventional MDCT staging were generated and compared. In addition, metastatic LN counts between the MDCT and the histopathological examinations and correlation between LN-sum and histopathological nodal status were analysed.

RESULTS

The total counts of metastatic LNs on MDCT was significantly smaller than those detected in histopathological assessments (p<0.0001). LN-sum showed significant correlation with the pathological N stage and the number of metastatic LNs (rho=0.69, 0.73, p<0.0001). The areas under the receiver operating characteristic curve were 0.896, and 0.835, for N stage ≥N2 and N3, with cut-off values of 12.5 and 23.5 mm, respectively. LN-sum provided better diagnostic performance than conventional MDCT staging for discriminating N0-2 versus N3; sensitivity, accuracy, PPV and NPV of LN-sum were significantly higher (80.4 versus 52.2%, 81.1 versus 68.5%, 71.2 versus 57.1%, and 88 versus 74.1%).

CONCLUSION

LN-sum may be sufficiently useful in assessing the N3 stage of AGC and may help to plan appropriate therapy for AGC patients.

Pathway of peritoneal carcinomatosis maybe hematogenous metastasis rather than peritoneal seeding

Goals

This study aimed to summarize the clinicopathological data of the cases of gastric cancer or colon cancer with regular metastasis in the mesentery of small intestine and explore the pathway of peritoneal carcinomatosis.

Materials and methods

We retrospectively analyzed 5 cases of gastric cancer and 3 cases of colon cancer with regular metastasis in the mesentery of the small intestine from January 2014 to June 2016, including clinical information, gross manifestations during operation, treatment, and pathology.

Results

The clinical characteristics of all 8 cases were fully collected. The symptoms were various without specificity. All patients were found to present with metastasis in peritoneum during operation and the metastatic lesions arranged along the blood vessels orderly. The metastatic lesions of all studied patients were proved to be malignant carcinoma histopathologically, the same as the original tumor. Tumor emboli were seen in the vessel and invasive neoplastic foci was also seen in the vascular wall.

Conclusions

The traditional view that peritoneal carcinomatosis is due to seeding has no sufficient basis. Hematogenous metastasis maybe the real way of peritoneal carcinomatosis combined with clinical presentation.

Clinical evaluation of CEA, CA19-9, CA72-4 and CA125 in gastric cancer patients with neoadjuvant chemotherapy

BACKGROUND

In the clinical practice of neoadjuvant chemotherapy, response markers are very important. We aimed o investigate whether tumor markers CEA(carcino-embryonic antigen), CA19-9(carbohydrate antigen 19-9), CA72-4(carbohydrate antigen 72-4), and CA125(carbohydrate antigen 125) can be used to evaluate the response to neoadjuvant chemotherapy, and to evaluate the diagnosis and prognosis value of four tumor markers in the patients of gastric cancer.

METHODS

A retrospective review was performed of 184 gastric cancer patients who underwent a 5-Fu, leucovorin, and oxaliplatin (FOLFOX) neoadjuvant chemotherapy regimen, followed by surgical treatment. Blood samples for CEA, CA19-9, CA72-4, and CA125 levels were taken from patients upon admission to the hospital and after neoadjuvant chemotherapy. Statistical analysis was performed to identify the clinical value of these tumor markers in predicting the survival and the response to neoadjuvant chemotherapy.

RESULTS

Median overall survival times of pretreatment CA19-9-positive and CA72-4-positive patients (14.0 +/-2.8 months and 14.8 +/-4.0 months, respectively) were significantly less than negative patients (32.5 +/-8.9 months and 34.0 +/-10.1 months, respectively) (P = 0.000 and P = 0.002, respectively). Pretreatment status of CA19-9 and CA72-4 were independent prognostic factors in gastric cancer patients (P = 0.029 and P = 0.008, respectively). Pretreatment CEA >50 ng/ml had a positive prediction value for clinical disease progression after neoadjuvant chemotherapy according to the ROC curve (AUC: 0.694, 95% CI: 0.517 to 0.871, P = 0.017). The decrease of tumor markers CEA, CA72-4, and CA125 was significant after neoadjuvant chemotherapy (P = 0.030, P = 0.010, and P = 0.009, respectively), especially in patients with disease control (including complete, partial clinical response, and stable disease) (P = 0.012, P = 0.020, and P = 0.025, respectively). A decrease in CA72-4 by more than 70% had a positive prediction value for pathologic response to neoadjuvant chemotherapy according to the ROC curve (AUC: 0.764, 95% CI: 0.584 to 0.945, P = 0.020).

CONCLUSIONS

Our results suggest that high preoperative serum levels of CA72-4 and CA19-9 are associated with higher risk of death, high pretreatment CEA levels (>50 ng/ml) may predict clinical disease progression after neoadjuvant chemotherapy, and a decrease (>70%) of CA72-4 may predict pathologic response to neoadjuvant chemotherapy.

Preoperative treatment and surgery in gastric cancer: friends or foes?

Until 2006, most reports of preoperative (neoadjuvant) treatments for gastric carcinoma were inconclusive and produced confusing results due to inhomogeneous treatment regimens, selection of patients, and response assessment. Since publication of the results from the MAGIC trial, substantial scientific evidence has suggested the benefits of perioperative (preoperative and postoperative) chemotherapy to locally advanced gastric cancer. To date, this phase III trial, coupled with preliminary data from other published reports on neoadjuvant chemotherapy and radiotherapy, supports the theoretical advantages of preoperative treatment for gastric carcinoma, thus introducing the concept of delayed surgery. Neoadjuvant treatment of resectable, locally advanced tumours might improve patients' outcomes and postpone the need for curative resection, but it also exposes patients to the risk of tumour progression.

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.

A PILOT STUDY OF PREOPERATIVE AND POSTOPERATIVE CHEMOTHERAPY IN PATIENTS WITH OPERABLE GASTRIC CANCER: AUSTRALASIAN GASTROINTESTINAL TRIALS GROUP STUDY 9601

BACKGROUND

With poor cure rates in gastric cancer using surgery alone, the safety, efficacy and feasibility of preoperative and postoperative chemotherapy was investigated.

METHODS

Patients with advanced but operable gastric or cardio-oesophageal adenocarcinoma were staged using endoscopy, computed tomography scan and laparoscopy. If considered potentially resectable, they received chemotherapy (epirubicin, cisplatin and 5-fluorouracil) for 9 weeks before and after surgery.

RESULTS

Of 59 participants entered, two were found to have metastatic disease and were excluded from the analysis. Of the participants, 10 were women and 47 men; their median age was 58 years (range 27-83 years) and median performance status 0 (range 0-1). Two of the 57 participants commencing chemotherapy did not undergo surgery (one sudden death, one new liver metastases). Grade 3 and 4 preoperative and postoperative toxicity rates were, respectively, neutropenia 22 and 18%, emesis 12 and 14% and other non-haematological toxicity <10 and <10%. Of the 55 who underwent surgery, 40 had apparently curative resections (clear or positive microscopic margins), 2 died after surgery (anastomotic leak, sepsis) and 16 had postoperative complications. Of these, 27 participants commenced postoperative chemotherapy and 21 completed it. Median progression-free survival and overall survival were 19.6 and 22 months, respectively.

CONCLUSION

Epirubicin, cisplatin and protracted venous infusion of 5-fluorouracil chemotherapy was well-tolerated in the preoperative setting and did not appear to increase complication rates of surgery for advanced and operable stomach cancer. These findings demonstrate the feasibility of this strategy in the Australasian clinical setting and are in keeping with the results of a recently reported randomized trial, which demonstrated a significant survival advantage using this chemotherapy regimen.

The role of staging laparoscopy in oesophagogastric cancers

AIMS

Selection of patients for treatment of oesophagogastric cancers rests on accurate staging. Laparoscopy has become a safe and effective staging tool in upper gastrointestinal cancers because of its ability to detect small peritoneal and liver metastases missed by imaging techniques. The aim of this study was to evaluate the role of staging laparoscopy (SL) in determining resectability of oesophagogastric cancers.

METHODS

A review of 511 patients with oesophagogastric cancers referred to our centre during a 7-year period was performed. Four hundred and sixteen of them assessed to have resectable tumours after preoperative staging with CT and/or ultrasound underwent SL. The main outcome measure was the number of patients in whom laparoscopy changed treatment decision.

RESULTS

Staging laparoscopy changed treatment decision in 84 cases (20.2%): locally advanced disease in 17, extensive lymph node disease in four and distant metastases (liver and peritoneum) in 63 cases. The sensitivity of laparoscopy for resectability was 88%. Eighty-one percent of patients who had combined CT scan and EUS were resectable at surgery compared with 65% of those who had CT scan alone (statistically significant with P-value<0.05). Of those patients deemed resectable by SL 8.1% were found to be unresectable at laparotomy, 16 with locally advanced disease and 11 with metastases.

CONCLUSION

Staging laparoscopy avoided unnecessary laparotomy in 20.2% of our patients and was most useful in adenocarcinoma, distal oesophageal, GOJ and gastric cancers and probably not necessary in lesions of the upper two-third of the oesophagus.

Apoptosis induced by preoperative oral 5’-DFUR administration in gastric adenocarcinoma and its mechanism of action

AIM: To study the apoptosis induced by preoperative oral 5’-DFUR administration in gastric adenocarcinoma and its mechanism of action.

METHODS: Sixty gastric cancer patients were divided randomly into three groups (20 each group) before operation: group one: 5’-DFUR oral administration at the dose of 800-1200mg/d for 3 - 5 d, group two: 500mg 5-FU + 200 mg/d CF by venous drip for 3 - 5 d, group three (control group). One or two days after chemotherapy, the patients were operated. Fas/FasL, PD-ECGF and PCNA were examined by immunohistochemistry and apoptotic tumor cells were detected by in situ TUNEL method. Fifty-four patients received gastrectomy, including 12 palliative resections and 42 radical resections. Six patients were excluded. Finally 18 cases in 5’-DFUR group, 16 cases in CF + 5-FU group, and 20 cases in control group were analyzed.

RESULTS: There was no significant difference in patient mean age, gender, white blood cell count, haematoglobin (HB), thromboplastin, perioperative complication incidence, radical or palliation resection, invasion depth (T), lymphonode involvement (N), metastasis (M) and TNM staging among the three groups. However, the PCNA index (PI) in 5’-DFUR group (40.51 ± 12.62) and 5-FU + CF group (41.12 ± 15.26) was significantly lower than that in control group (58.33 ± 15.69) (F = 9.083, P = 0.000). The apoptotic index (AI) in 5’-DFUR group (14.39 ± 9.49) and 5-FU + CF group (14.11±9.68) was significantly higher than that in control group (6.88 ± 7.37) (F = 4.409, P = 0.017). The expression rates of Fas and FasL in group one and group three were 66.7% (12/18) and 50% (9/18), 43.8% (7/16) and 81.3% (13/16), 45.0% (9/20) and 85% (17/20), respectively. The expression rate of FasL in 5’-DFUR group was significantly lower than that in the other two groups (χ²=6.708, P = 0.035). Meanwhile, the expression rate of PD-ECGF was significantly lower in 5’-DFUR group (4/18，28.6%) than in CF + 5-FU group（9/16，56.3%）and control group (13/20，65.0%) (χ²= 7.542, P = 0.023). The frequency of Fas expression was significantly correlated with palliative or radical resection (χ²= 7.651, P = 0.006), invasion depth (χ²= 8.927, P = 0.003), lymphatic spread (χ²= 4.488, P = 0.034) and UICC stages (χ²= 8.063, P = 0.045) respectively. By the end of March 2005, 45 patients were followed up. The 0.5-, 1-, 2-, 3-year survival rates were 96%，73%，60%，48%, respectively, which were related with T, N, M and Fas expression, but not with PD-ECGF and FasL expression.

CONCLUSION: Preoperative oral 5’-DFUR administration may induce apoptosis of gastric carcinoma cells and decrease tumor cell proliferation index, but cannot improve the prognosis of patients with gastric cancer. Down-regulation of FasL and PD-ECGF expression mediated by 5’-DFUR may be one of its anti-cancer mechanisms. Fas expression correlates with the progression of gastric carcinoma and may be an effective prognostic factor.

Disseminated tumor cells in the blood of patients with gastric cancer are an independent predictive marker of poor prognosis

OBJECTIVE

Gastric cancer carries a poor prognosis even after curative resection (R0). Tumor progression in gastric cancer patients has been attributed to the persistence of disseminated tumor cells (DTC) in various body compartments as a sign of minimal residual disease, although the prognostic relevance of DTC is still unclear. In this study the prognostic relevance of DTC in the blood of gastric cancer patients was investigated.

MATERIALS AND METHODS

Venous blood samples of 70 cancer patients were taken intraoperatively before surgical manipulation and examined by reverse transcription-polymerase chain reaction (RT-PCR) for expression of cytokeratin 20 (CK20) as a marker for DTC. Tumor-related survival was analyzed using univariate and multivariate models assessing occurrence of DTC, residual tumor classification, and tumor stage. Median follow-up was 20 months (range 1-57 months).

RESULTS

Twenty-eight of the 70 patients (40%) were CK20 positive. The prevalence of DTC in patients following R0 resection (15/41, 37%) was similar to that in patients with residual tumor (13/29, 45%, NS). Furthermore, expression of CK20 was independent of TNM stage. Univariate analysis of R0-resected patients revealed CK20 to be a marker for significantly shorter tumor-related survival (p = 0.0363). In a multivariate analysis, CK20 was an independent prognostic marker. Detection of CK20 had greatest impact for early tumor stages (T1 and T2, N0; p < 0.0032).

CONCLUSIONS

Detection of DTC in venous blood of gastric cancer patients is an independent predictive marker of poor prognosis and thus could help to define patients for adjuvant therapy with this tumor entity.

Multivariate analysis of the risk for pulmonary complication after gastrointestinal surgery

AIM: To identify the risk factors for postoperative pulmonary complications (PPC) after gastrointestinal surgery.

METHODS: A total of 1002 patients undergoing gastrointestinal surgery in the Second Affiliated Hospital, Sun Yat-Sen University, during December 1999 and December 2003, were retrospectively studied.

RESULTS: The overall incidence of PPC was 22.8% (228/1002). Multivariate logistic analysis identified nine risk factors associated with PPC, including age odds ratio (OR = 1.040) history of respiratory diseases (OR = 2.976), serum albumin (OR = 0.954), chemotherapy 2 wk before operation (OR = 3.214), volume of preoperative erythrocyte transfusion (OR = 1.002), length of preoperative antibiotic therapy (OR = 1.072), intraoperative intratracheal intubation (OR = 1.002), nasogastric intubation (OR = 1.050) and postoperative mechanical ventilation (OR = 1.878). Logistic regression equation for predicting the risk of PPC was P(1) = 1/[1+e^{-(-3.488+ 0.039×Y+1.090×Rd+0.001×Rbc-0.047×Alb+0.002×Lii+ 0.049×Lni+0.630×Lmv+0.070×Dat+ 1.168×Ct)}].

CONCLUSION: Old patients are easier to develop PPC.

Prognostic indicators in locally advanced gastric cancer (LAGC) treated with preoperative chemotherapy and D2-gastrectomy

BACKGROUND AND OBJECTIVES

Neoadjuvant chemotherapy is increasingly considered an effective treatment option for patients with gastric carcinoma. Aim of the study is to evaluate the prognostic significance of the pathological response and of known prognostic factors in a group of accurately staged locally advanced gastric cancer (LAGC) patients.

METHODS

Thirty-three patients with LAGC, staged by laparoscopy, underwent D2-gastrectomy after preoperative chemotherapy. Survival was calculated by Kaplan-Meier method and differences were assessed by the Log-rank and Breslow test. Multivariate analysis was performed using the Cox proportional hazard model in backward stepwise regression.

RESULTS

Curative resection (R0) was achieved in 81.8% of patients. A complete or subtotal pathological response was documented in 3 and 6%, respectively. Nineteen out of thirty-three (57.6%) patients were alive and 16 of them were free of relapse at last follow-up. Survival rates were 81, 67, and 59% at 12, 24, and 36 months, respectively. At univariate and multivariate analysis, only R0 resection was found to be an independent prognostic factor.

CONCLUSIONS

In the current study, R0 resection is the most important prognostic factor for resectable LAGC; according to our results we feel encouraged to consider neoadjuvant chemotherapy a promising modality for increasing the R0-percentage of gastric carcinoma patients who could benefit from a curative surgery.

Clinicopathological significance and survival influence of p53 protein expression in gastric carcinoma

AIMS

Mutations in the gene coding for p53 protein are among the most frequent genetic alterations observed in human cancers. The relevance and biological significance of p53 expression in gastric carcinoma are far from being fully established. The aim of our study was to evaluate the influence of p53 detected by immunohistochemistry in the clinicopathological behaviour of a series of gastric carcinoma cases.

METHODS AND RESULTS

Samples from 163 patients treated by gastric resection for gastric carcinoma between 1988 and 1995 were used. Surgical specimens were evaluated for the presence of p53 protein detected by immunohistochemistry with a monoclonal antibody. Cases were classified as positive or negative for p53. Several clinicopathological parameters and c-erb B-2 expression were analysed in the same series and compared with the expression of p53. Cumulative survival was evaluated using univariate analysis and Cox model regression. p53 expression was identified in 41 carcinomas (25.2%) and was significantly associated with venous invasion (P = 0.049), lymph node metastases (P = 0.01) and c-erb B-2 expression (P = 0.003). All the parameters except gender, tumour size and Laurén's classification influenced survival on univariate analysis. p53 expression correlated with overall survival (P = 0.006) and survival in the subgroup of patients with intestinal type carcinoma (P = 0.04). In the subgroup of patients with carcinomas not expressing c-erb B-2, p53 expression significantly influenced cumulative survival (P = 0.02).

CONCLUSIONS

p53 expression is associated with the aggressive biological behaviour of gastric carcinomas and is related to cumulative survival.

(Neo)adjuvant strategies of advanced gastric carcinoma: time for a change?

Despite surgical R0 resections, patients with gastric cancer stage UICC II-III have a high risk of recurrence and metachronic metastases. Preliminary evidence exists that adjuvant chemotherapy or neoadjuvant chemo(radio)therapy protocols may improve the prognosis of these patients undergoing surgery of gastric cancer with curative intention. As for palliative regimens, 5-fluorouracil and cisplatin are integral components of such (neo)adjuvant strategies. Upcoming cytostatic agents, i.e. irinotecan, docetaxel, oxaliplatin, and oral fluoropyridines are currently under investigation in new multimodality treatment regimens and may further increase R0 resection rates and may prolong disease-free and overall survival in the treatment of advanced localized gastric cancer.

Complications of gastrectomy following CPT-11-based neoadjuvant chemotherapy for gastric cancer

Potential benefits of neoadjuvant therapy for locally advanced gastric cancer include tumor downstaging and an increased R0 resection rate. Potential disadvantages include increased surgical complications. This study assesses postoperative morbidity and mortality by comparing patients undergoing gastrectomy with and without neoadjuvant chemotherapy. From October 1998 to July 2002, a total of 34 patients with locally advanced gastric cancer were placed on a phase II neoadjuvant chemotherapy protocol consisting of two cycles of CPT-11 (75 mg/m(2)) with cisplatin (25 mg/m(2)). Demographic, clinical, morbidity, and mortality data were compared for these patients (CHEMO) versus 85 patients undergoing gastrectomy without neoadjuvant chemotherapy (SURG). The CHEMO patients were more likely to be less than 70 years of age (P< or =0.01), have proximal tumors (P< or =0.01), and undergo proximal gastrectomy (P< or =0.025). Fifty-two percent of SURG patients had T3/T4 tumors compared to 19% of CHEMO patients, consistent with tumor downstaging. The R0 resection rate was similar (80%). Morbidity was 41% in CHEMO patients and 39% in SURG patients. There were five postoperative deaths (4.4%), two in the CHEMO group and three in the SURG group (P=NS). It was concluded that neoadjuvant chemotherapy with CPT-11 and cisplatin is not associated with increased postoperative morbidity compared to surgery alone. CPT-11-based neoadjuvant chemotherapy should be tested further in combined-modality treatment of gastric cancer.

Neoadjuvant chemotherapy, radical resection with intraoperative radiation therapy (IORT): improved treatment for gastric adenocarcinoma

BACKGROUND

Adenocarcinoma of the stomach and gastroesophageal junction results in substantial morbidity, locoregional recurrence, and death. Surgical procedures, even with adjuvant therapy, have not significantly improved survival. This study evaluated the toxicity, response rate, locoregional control, and survival of patients with locally advanced gastric cancer that was treated with neoadjuvant multimodality therapy.

METHODS

Patients with stage IIIA or early stage IV gastric adenocarcinoma received neoadjuvant 5-fluorouracil, Leucovorin, Adriamycin, and Cisplatin and underwent gastrectomy or esophagogastrectomy with intraoperative radiotherapy (IORT; 1000 cGY) to the gastric bed and postoperative radiation therapy.

RESULTS

Nine of 15 patients (60%) with transmural extension and/or nodal metastases received IORT. There were 2 pathologically complete responses at the primary site. Eleven of 15 patients (73%) had tumor in perigastric lymph nodes; however, 9 of 15 patients (60%) had mucin-filled nodes without tumor cells. Neoadjuvant treatment did not increase operative morbidity rates. Ten of 15 patients (67%) remain free of disease (median, 27 months; range, 6-60 months). Five patients died 13 to 41 months (median, 17 months) after diagnosis.

CONCLUSIONS

Neoadjuvant multimodality therapy with neoadjuvant 5-fluorouracil, Leucovorin, Adriamycin, and Cisplatin, radical resection with IORT, and postoperative radiation therapy is safe, can downstage tumors, provides improved locoregional control, and appears to cause significant tumor regression that may result in long-term survival or cure.

Multidisciplinary approach to esophageal and gastric cancer

Despite marked advances in surgical therapy for patients with esophageal, esophagogastric, and gastric cancers, the overall prognosis of these patients has not markedly improved during the past decades. Multidisciplinary approaches using adjuvant postoperative and neoadjuvant preoperative therapeutic principles have received increasing attention with regard to the management of these patients. A series of randomized, prospective trials has demonstrated that adjuvant postoperative radiation or chemotherapy does not result in a convincing survival advantage after complete tumor resection in esophageal, esophagogastric junction, or gastric cancer. The available data on the role of neoadjuvant preoperative therapy are not yet conclusive. Although neoadjuvant therapy may reduce the tumor mass in many patients, several randomized, controlled trials have shown that, compared with primary resection, a multimodal approach does not result in a survival benefit in patients with locoregional, that is, potentially resectable, tumors. In contrast, in patients with locally advanced tumors, that is, patients in whom complete tumor removal with primary surgery seems unlikely, neoadjuvant therapy increases the likelihood of complete tumor resection on subsequent surgery, but only patients with objective histopathologic response to preoperative therapy seem to benefit from this approach. Consequently, in the future, improvements in the overall survival of patients with esophageal, esophagogastric junction, or gastric cancer most likely will be achieved only by tailored therapeutic strategies that are based on the individual tumor location, tumor stage, and consideration of established prognostic factors. A clear classification of the underlying tumor entity, a profound knowledge of the prognostic factors applicable, a thorough preoperative staging, and identification of parameters that allow for the prediction of response to preoperative therapy will become essential for the selection of the optimal therapeutic modality for individual patients.

Palliative superselective intra-arterial chemotherapy for advanced nonresectable gastric cancer

From November 1988 to May 1996, a prospective randomized study was undertaken to assess the efficacy of superselective intra-arterial chemotherapy for surgically proved unresectable gastric carcinoma. Each patient had undergone endoscopy as well as abdominal and pelvic CT scanning for staging. Patients with evidence of liver metastasis, peritoneal carcinomatosis, enlarged retroperitoneal lymph nodes, or locally advanced disease beyond curative resection were excluded from the study. A total of 386 patients with potentially curable disease were randomized to one of three treatment groups: (1) control; (2) systemic intravenous chemotherapy; or (3) superselective intra-arterial chemotherapy. On completion of preoperative chemotherapy, all patients underwent operative exploration with curative intent. A total of 74 consecutive patients were found to be unresectable, as evidenced by the presence of liver metastasis, peritoneal carcinomatosis, enlarged retroperitoneal lymph nodes, or locally extensive disease not detected by preoperative CT scanning. The median survival time in the control group and after intravenous chemotherapy was only 91 and 96 days, respectively, as compared to 401 days in the patients receiving intra-arterial chemotherapy. The results confirmed that superselective intra-arterial chemotherapy conferred a highly significant survival advantage compared to control or systemic intravenous chemotherapy adjusted for all patient characteristics (P <0.0001).

Role of laparoscopy in the management of stomach cancer

The use of laparoscopy for staging and treatment of gastric cancer has evolved in the past decade along with other advanced laparoscopic procedures. Laparoscopic staging of gastric cancer, especially with the addition of laparoscopic ultrasonography, has been shown more reliable than radiologic modalities and it effectively decreases the incidence of unnecessary laparotomy. Although it is not commonly performed in Western countries, the use of laparoscopic curative resection for gastric cancer is growing, especially in Japan. Laparoscopic resection of early gastric cancer has been shown to be safe and effective in many retrospective series though no prospective randomized studies comparing it to open resection have been performed. Despite being more controversial, laparoscopic curative resection of advanced gastric cancer also has been performed at multiple institutions with encouraging early results. This review will present the current worldwide experience of laparoscopy for gastric cancer.

Response to neoadjuvant chemotherapy best predicts survival after curative resection of gastric cancer

OBJECTIVE

In Western populations, long-term survival rates after curative resection of gastric cancer remain extremely poor. The lack of effective adjuvant therapy has prompted the evaluation of neoadjuvant approaches. Since 1988, we have conducted three separate phase II trials using neoadjuvant chemotherapy to treat patients with potentially resectable gastric cancer. The present study was conducted to evaluate whether response to neoadjuvant chemotherapy is predictive of survival in patients with resectable gastric cancer.

METHODS

Eighty-three patients with pathologically confirmed gastric adenocarcinoma were treated with neoadjuvant chemotherapy before planned surgical resection. Response was assessed by upper gastrointestinal series, endoscopy, computed tomography scan, and pathologic examination.

RESULTS

For the three phase II trials, clinical response rates ranged from 24% to 38%. Three patients (4%) had a complete pathologic response. Sixty-one patients (73%) underwent a curative resection. Median follow-up was 26 months. Univariate analysis revealed T stage, number of positive nodes, and response to chemotherapy to be significant predictors of overall survival. However, on multivariate analysis, response to chemotherapy was found to be the only independent prognostic factor.

CONCLUSIONS

Response to neoadjuvant chemotherapy is the single most important predictor of overall survival after neoadjuvant chemotherapy for gastric cancer. These findings support further evaluation of neoadjuvant approaches in the treatment of this disease.

Laparoscopic ultrasonography for staging gastroesophageal cancer

BACKGROUND

TNM staging of gastroesophageal cancer is improved by the use of laparoscopy for the detection of occult metastases and endoscopic ultrasonography for T and possibly N staging. Laparoscopic ultrasonography may combine the strengths of both of these techniques. The purpose of this study was to compare TNM staging by means of laparoscopic ultrasonography (Lap US), laparoscopy, and conventional computed tomography (CT).

METHODS

TNM stage was determined by using Lap US, laparoscopy, and CT scanning in 26 surgical candidates with gastric or esophageal cancer in a blinded fashion. CT scans were also reviewed separately by an expert radiologist. Validation of findings was by means of final pathologic examination.

RESULTS

Resectability for potential cure was determined by means of Lap US with a sensitivity of 100% and a specificity of 91% versus 100% and 73% for laparoscopy and 75% and 60% for CT, respectively. Overall TNM staging was 82% accurate for Lap US versus 67% for laparoscopy and 47% for CT (chi-squared, 8.64, p < 0.005, and 10.4, p < 0.005, respectively). Accuracies for Lap US versus laparoscopy versus CT for N stage were 92% versus 84% versus 70%, respectively, for T stage were 92% versus 42% versus 60%, respectively, and for M stage were 89% versus 44% versus 62%, respectively.

CONCLUSIONS

T and N staging by Lap US were comparable to published results for endoscopic ultrasonography, and overall TNM staging was better. Lap US may provide the optimal preoperative staging for gastric cancer and has the potential to complement endoscopic ultrasonography in staging esophageal cancer.