The role of radiotherapy in the surgical management of gastrointestinal cancer

Neoadjuvant Chemoradiation Treatment for Resectable Esophago-Gastric Cancer: A Systematic Review and Meta-Analysis

Background: Neoadjuvant chemoradiation (CRT) remains controversial in the treatment of the oesophagus or gastro-oesophageal junction (GOJ) carcinomas.

Methods: We conducted a meta-analysis to assess the efficacy and safety of Neoadjuvant CRT plus surgery comparing with neoadjuvant CT plus surgery or surgery alone. Feasible studies were searched from electronic databases. The outcomes of survival, R0 resection rate and adverse effects were analyzed. The outcomes were measured with relative risk (RR) and odds ratio(OR).

Results: Seventeen records including 4095 patients were included. Neoadjuvant CRT improved 1-,2-,3-and 5-year survival. The relative risk (RR) [95% confidence interval (CI),P value] was respectively 1.08(1.03-1.14,0.002), 1.21(1.12-1.32,<0.00001),1.31(1.09-1.58,0.004),1.38(1.17-1.62, <0.001).In subgroup analysis, patients with squamous cell carcinoma benefited more survival advantage from neoadjuvant CRT than those with adenocarcinoma[1.23(1.15-1.33)vs1.11 (1.03-1.19)]. A significant advantage was observed in analysis of neoadjuvant CRT for PFS [1.32 (1.22-1.44),<0.00001]. Tests for DFS between neoadjuvant CRT and neoadjuvant CT or surgery alone were not statistically significant[1.06 (0.97-1.17,0.19)]. Neoadjuvant CRT was associated with higher R0 resection [2.58(1.75-3.82),<0.00001] and pCR rate [4.37(2.68-7.13),<0.00001]. Neoadjuvant CRT lowered the local recurrence rate [0.52(0.39-0.69),<0.00001] and didn't control distant metastasis rate[0.85(0.67-1.08),0.19].There was no evidence that neoadjuvant CRT increased the treatment-related mortality[1.27(0.95-1.71),0.11]. Neoadjuvant CRT plus surgery did not increase the risk of adverse events morbidity[1.14(0.99-1.32),0.08].

Conclusion: Patients with oesophagus or GOJ carcinomas can obtain a survival advantage from neoadjuvant CRT. The addition of radiation was efficacy and safe in range. However, these results need further high-quality prospective RCTs confirmation.

Curative treatment of gastric cancer: towards a multidisciplinary approach?

Despite marked decreases in incidence over the last century, particularly in developed countries, gastric cancer is still the second-most common tumor worldwide. Surgery remains the gold standard for the cure of locoregional disease. However, in most countries, the diagnosis is made at an advanced stage, and the 5-year survival for surgically resectable disease stays far below 50%. The efficacy of chemotherapy and/or radiation therapy in addition to surgery has been actively studied over the last 30 years. Unfortunately, with few exceptions, most studies of adjuvant therapy in gastric cancer have given deceiving results. The purpose of this review is to address the reasons for our failure to objectivate an improvement in the cure of gastric cancer with adjuvant treatment in most trials, and to consider potential solutions. The low efficacy of chemotherapy regimens available up to now may have hampered our progress. In addition, many previous studies suffered limitations of design or methodology (e.g. low accrual, inadequate disease stage selection, inadequate surgical treatment) that may have obscured a treatment effect. Furthermore, the reduced treatment tolerance of post-gastrectomy patients, perhaps due to their poor nutritional status, results in decreased or delayed adjuvant systemic therapy, with potential adverse consequences in its efficacy. Among potential solutions, the arrival of new drugs, taxanes and topoisomerase I inhibitors in particular, which have shown encouraging results in metastatic disease, may increase the impact of chemotherapy in a multidisciplinary treatment approach. Pre-treatment with chemotherapy and/or radiation therapy prior to surgery may also be advantageous, averting the problems associated with post-surgical treatment. Such an approach has been shown to be feasible in phase II studies, and is relatively well tolerated by patients. Several carefully designed randomized phase III trials are underway to answer this question.

Neoadjuvant radiochemotherapy for locally advanced gastric cancer: a phase I-II study

BACKGROUND

To study in a phase I-II trial the maximum tolerated dose, the toxicity, and the tolerance of adding radiotherapy to systemic chemotherapy administered preoperatively in patients with locoregionally advanced gastric adenocarcinoma.

PATIENTS AND METHODS

Patients with adenocarcinoma of the stomach (T(3)(-)(4)N(any) or T(any)N+), performance status </=1, normal hematological, hepatic and renal functions received two cycles of cisplatin 100 mg/m(2) on day 1, 5-FU 800 mg/m(2) on days 1 to 4 and leucovorin 60 mg b.i.d. on days 1 to 4 q3w, concomitantly with radiation therapy escalated in three dose tiers (31.2, 38.4 and 45.6 Gy).

RESULTS

Nineteen patients were accrued and 18 completed neoadjuvant therapy. Major toxicity consisted of grade 3/4 leucopenia and mucositis in 89% and 36% of the patients, respectively. Only one episode of febrile neutropenia was recorded. Dose level number 2 (38.4 Gy) with the chemotherapy given q4w is the recommended dose level. All patients were subsequently operated and no fatalities occurred. Pathological assessment showed one complete and eight partial responses. Two- and 3-year relapse-free survival rates were 57% and 50%, respectively. Only one patient relapsed locally. The peritoneum was the most frequent site of relapse.

CONCLUSIONS

This neoadjuvant therapeutic program is relatively well tolerated, does not seem to increase the operative risk, and might increase the locoregional control of the disease. The frequency of peritoneal involvement in relapsing patients underscores the need for a more effective systemic treatment.