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Yeh JH, Yeh YS, Tsai HL, Huang CW, Chang TK, Su WC, Wang JY. Neoadjuvant Chemoradiotherapy for Locally Advanced Gastric Cancer: Where Are We at? Cancers (Basel) 2022; 14:cancers14123026. [PMID: 35740693 PMCID: PMC9221037 DOI: 10.3390/cancers14123026] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 06/13/2022] [Accepted: 06/17/2022] [Indexed: 02/06/2023] Open
Abstract
Simple Summary More than 50% of gastric cancer are at least locally advanced at presentation. For such patients, a multimodal approach rather than mere surgical resection leads to better long-term prognosis. Neoadjuvant chemoradiotherapy is one of the common treatment strategies for local advanced gastric cancer. Based on the experience and evidence from esophago-gastric cancers, the incorporation of systemic and locoregional therapy has shown superior disease control and reduced local recurrence. However, the optimal chemotherapy regimen, patient selection, technical consideration and potential biomarkers are still under investigation. Furthermore, the comparison of neoadjuvant chemoradiotherapy with neoadjuvant/perioperative chemotherapy is also an important issue to be answered. In the review article, we addressed the current available evidence to provide a comprehensive understanding and the use of neoadjuvant chemoradiotherapy for locally advanced gastric cancer. Future studies and ongoing trials will be necessary to determine the best candidate and the role of newer systemic and radiation therapies in such patients. NCRT is a feasible treatment option for LAGC, with the ability to achieve favorable disease control and enable higher radical resection rates over those afforded by perioperative chemotherapy or surgery alone. Large clinical trials examining the comparative efficacy of NCRT and NCT are underway. The discrepancy between the satisfactory pCR rates associated with NCRT and the nonsignificant association between NCRT and survival warrants further exploration. Furthermore, newer therapies such as immunotherapy and adaptive radiotherapy may be implemented in con-junction with NCRT, and the development of useful biomarkers may ultimately lead to the de-velopment of personalized treatments for LAGC. These research directions may lead to the dis-covery of the optimal approach to administering NCRT to patients with LAGC. They may also aid in the determination of the optimal candidates for undergoing NCRT. Abstract Locally advanced gastric cancer (LAGC) has a poor prognosis with surgical resection alone, and neoadjuvant treatment has been recommended to improve surgical and oncological outcomes. Although neoadjuvant chemotherapy has been established to be effective for LAGC, the role of neoadjuvant chemoradiotherapy (NCRT) remains under investigation. Clinical experience and research evidence on esophagogastric junction adenocarcinoma (e.g., cardia gastric cancers) indicate that the likelihood of achieving sustainable local control is higher through NCRT than through resection alone. Furthermore, NCRT also has an acceptable treatment-related toxicity and adverse event profile. In particular, it increases the likelihood of achieving an R0 resection and a pathological complete response (pCR). Moreover, NCRT results in higher overall and recurrence-free survival rates than surgery alone; however, evidence on the survival benefits of NCRT versus neoadjuvant chemotherapy (NCT) remains conflicting. For noncardia gastric cancer, the efficacy of NCRT has mostly been reported in retrospective studies, and several large clinical trials are ongoing. Consequently, NCRT might play a more essential role in unresectable LAGC, for which NCT alone may not be adequate to attain disease control. The continual improvements in systemic treatments, radiotherapy techniques, and emerging biomarkers can also lead to improved personalized therapy for NCRT. To elucidate the contributions of NCRT to gastric cancer treatment in the future, the efficacy, potential toxicity, predictive biomarkers, and clinical considerations for implementing NCRT in different types of LAGC were reviewed.
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Affiliation(s)
- Jen-Hao Yeh
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan; (J.-H.Y.); (T.-K.C.); (W.-C.S.)
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, E-DA Dachang Hospital, Kaohsiung 82445, Taiwan
- Department of Medical technology, College of Medicine, I-Shou University, Kaohsiung 82445, Taiwan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, E-DA Hospital, Kaohsiung 82445, Taiwan
| | - Yung-Sung Yeh
- Division of Trauma and Surgical Critical Care, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan;
- Department of Emergency Medicine, Faculty of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei 11031, Taiwan
| | - Hsiang-Lin Tsai
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan; (H.-L.T.); (C.-W.H.)
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Ching-Wen Huang
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan; (H.-L.T.); (C.-W.H.)
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Tsung-Kun Chang
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan; (J.-H.Y.); (T.-K.C.); (W.-C.S.)
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan; (H.-L.T.); (C.-W.H.)
- Department of Surgery, Faculty of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Wei-Chih Su
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan; (J.-H.Y.); (T.-K.C.); (W.-C.S.)
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan; (H.-L.T.); (C.-W.H.)
| | - Jaw-Yuan Wang
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan; (J.-H.Y.); (T.-K.C.); (W.-C.S.)
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan; (H.-L.T.); (C.-W.H.)
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Center for Cancer Research, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Cohort Research Center, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Pingtung Hospital, Ministry of Health and Welfare, Pingtung 90054, Taiwan
- Correspondence: ; Tel.: +886-7-3122805; Fax: +886-7-3114679
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Observational Study Comparing Efficacy and Safety between Neoadjuvant Concurrent Chemoradiotherapy and Chemotherapy for Patients with Unresectable Locally Advanced or Metastatic Gastric Cancer. JOURNAL OF ONCOLOGY 2020; 2020:6931317. [PMID: 32963531 PMCID: PMC7492932 DOI: 10.1155/2020/6931317] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/07/2020] [Accepted: 07/15/2020] [Indexed: 02/08/2023]
Abstract
Objective Dismal outcomes in patients with locally advanced or metastatic gastric cancer (GC) highlight the need for effective systemic neoadjuvant treatment strategies to improve clinical results. Neoadjuvant multimodality strategies vary widely. This study compared the efficacy, safety, and clinical outcomes of neoadjuvant CCRT and chemotherapy for such patients. Materials and Methods Sixty-five patients with histologically confirmed locally advanced or metastatic GC following neoadjuvant CCRT or computed tomography (CT) were retrospectively enrolled between January 2010 and April 2019. Clinical outcomes included response, progression-free survival (PFS), and overall survival (OS), and toxicity was compared between the two groups. Results Of the 65 patients, 18 (27.7%) were in the response group (2 patients with a complete response and 16 with a partial response) and 47 (72.3%) in the nonresponse group (29 patients with a stable disease and 18 with a progressive disease). Multivariate analysis revealed no independent response predictor between CCRT and chemotherapy groups (all P > 0.05). Furthermore, results revealed no statistical differences in toxicity between the two groups (all P > 0.05). With a follow-up median of 12 months (ranging 6–48 months), 12-month OS and PFS were 39.7% and 20.4% in the CCRT group and 30.3% and 13.2% in the chemotherapy group, respectively. The median OS and PFS were 14.0 months (95% CI 9.661–18.339) and 9.0 months (95% CI 6.805–11.195) in the CCRT group and 10.0 months (95% CI 6.523–13.477) and 8.0 months (95% CI 6.927–9.073) in the chemotherapy group, respectively. Both OS (P=0.011) and PFS (P=0.008) in patients with CCRT were significantly better than those in patients with chemotherapy alone. Conclusion Neoadjuvant CCRT achieved more favorable OS and PFS than did neoadjuvant chemotherapy alone, without significant increases of toxicity in patients. However, prospective randomized trials comparing treatment modalities are necessary to confirm the potential advantages of neoadjuvant CCRT.
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Liu F, Zhou R, Jiang F, Liu G, Li K, Zhu G. Proposal of a Nomogram for Predicting Survival in Patients with Siewert Type II Adenocarcinoma of the Esophagogastric Junction After Preoperative Radiation. Ann Surg Oncol 2019; 26:1292-1300. [PMID: 30805805 PMCID: PMC6456486 DOI: 10.1245/s10434-019-07237-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Indexed: 12/12/2022]
Abstract
Background Preoperative radiotherapy tends to be more frequently used for patients with adenocarcinoma of the esophagogastric junction (AEG); however, the prognostic values of postoperative pathologic characteristics in these patients remain unclear. This study aimed to examine the outcomes in Siewert type II AEG patients receiving preoperative radiotherapy to identify the predictive factors for overall survival (OS). Methods and Results A total of 1818 AEG patients undergoing preoperative radiotherapy were reviewed. Univariate analyses showed that age, sex, histology, tumor grade, positive lymph node (PLN), lymph node ratio, and log odds of positive lymph nodes (LODDS) were significantly correlated with OS; however, only age, grade, PLN, and LODDS were identified as independent risk factors in a multivariate regression model. Subsequently, patients were randomly grouped into training and validation cohorts (1:1 ratio), and the beta coefficients of these variables in the training set were used to generate the nomogram. The composite nomogram showed improved prognostic accuracy in the training, validation, and entire cohorts compared with that of TNM stage alone. Conclusions In conclusion, our proposed nomogram represents a promising tool for estimating OS in Siewert type II AEG patients after preoperative radiotherapy. Electronic supplementary material The online version of this article (10.1245/s10434-019-07237-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Feng Liu
- Department of Geriatrics, National Clinical Key Specialty, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, 510180, Guangdong, China
| | - Rui Zhou
- Department of Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Funeng Jiang
- Department of Geriatrics, National Clinical Key Specialty, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, 510180, Guangdong, China
| | - Guolong Liu
- Department of Geriatrics, National Clinical Key Specialty, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, 510180, Guangdong, China
| | - Kangbao Li
- Department of Geriatrics, National Clinical Key Specialty, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, 510180, Guangdong, China
| | - Guodong Zhu
- Department of Geriatrics, National Clinical Key Specialty, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, 510180, Guangdong, China.
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Zhao Q, Li Y, Yu B, Yang P, Fan L, Tan B, Tian Y. Effects of Preoperative Enteral Nutrition on Postoperative Recent Nutritional Status in Patients with Siewert II and III Adenocarcinoma of Esophagogastric Junction after Neoadjuvant Chemoradiotherapy. Nutr Cancer 2018; 70:895-903. [PMID: 30273016 DOI: 10.1080/01635581.2018.1490780] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Qun Zhao
- Third Department of Surgery, The Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, PR China
| | - Yong Li
- Third Department of Surgery, The Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, PR China
| | - Bin Yu
- Third Department of Surgery, The Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, PR China
| | - Peigang Yang
- Third Department of Surgery, The Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, PR China
| | - Liqiao Fan
- Third Department of Surgery, The Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, PR China
| | - Bibo Tan
- Third Department of Surgery, The Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, PR China
| | - Yuan Tian
- Third Department of Surgery, The Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, PR China
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Ahmed S, Fawzy M, Rezk K, Elshrif W, Alaa M, Ellah MMHA. Preoperative Conformal Radiotherapy Concurrently with Paclitaxel/Carboplatin in Gastric Cancer. JOURNAL OF CANCER THERAPY 2018; 09:503-515. [DOI: 10.4236/jct.2018.96041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Evaluation of Tumor Resectability Rate and Pathologic Response to Preoperative Concurrent Chemoradiotherapy in Locally Advanced Proximal Gastric and Esophagogastric Junction Adenocarcinomas: A Clinical Trial. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2017. [DOI: 10.5812/ijcm.7473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Histopathologic Features are more Important Prognostic Factors than Primary Tumour Location in Gastro-oesophageal Adenocarcinoma Treated with Preoperative Chemoradiation and Surgery. Pathol Oncol Res 2017; 24:373-383. [PMID: 28550507 DOI: 10.1007/s12253-017-0253-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 05/17/2017] [Indexed: 02/07/2023]
Abstract
The aim of present study was to evaluate the impact of primary tumour location and other factors on the outcome of preoperative chemoradiation followed by surgery in adenocarcinomas of distal oesophagus, gastro-oesophageal junction and stomach. We retrospectively reviewed the institutional patient database. The therapeutic response was re-evaluated as a percentage of residual tumor cells in surgical resection specimens. Overall survival (OS) and disease-free survival (DFS) were assessed. The effect primary tumour location, clinical and pathological TNM stage, and histopathological factors (histological type, grade, angioinvasion, perineural invasion, tumour response) on treatment outcome were evaluated. A total of 108 patients underwent preoperative chemoradiation for adenocarcinoma of distal oesophagus, gastro-oesophageal junction or stomach. The median prescribed dose of radiation was 45 Gy. The concurrent chemotherapy consisted of 5-fluorouracil +/- cisplatin +/- taxanes. R0 resection was achieved in 80 patients (74%). The complete response was observed in 19%. The median follow-up was 50.8 months. Three-year and 5-year OS and DFS were 36.2% and 25.3%; and 28.1% and 23.7%, respectively. Pretreatment T-stage, pathological N-stage, radicality of resection, histological subtype, grade, angioinvasion and perineural invasion, were identified as statistical significant OS predictors in univariate analysis; pathological N-stage, radicality of resection and angioinvasion, in multivariate analysis. The primary tumor location did not influence the prognosis. The pathologic response to chemoradiation had borderline significance. In conclusion, no prognostic impact of primary tumour location, in contrast to other investigated factors, was evident in the present study. The most important predictors of prognosis were angioinvasion status and pN-stage.
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Concurrent Neoadjuvant Chemoradiotherapy for Siewert II and III Adenocarcinoma at Gastroesophageal Junction. Am J Med Sci 2015; 349:472-6. [PMID: 25996101 PMCID: PMC4450970 DOI: 10.1097/maj.0000000000000476] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE This study was conducted to investigate the efficacy and safety of using a concurrent neoadjuvant chemoradiotherapy (a XELOX regimen) to treat adenocarcinoma of the gastroesophageal junction. METHODS Seventy-six patients having resectable adenocarcinoma at the gastroesophageal junction (T3/4, N+, M0) were recruited to participate and randomly assigned to either a chemoradiotherapy group or a surgery group. Patients in the chemoradiotherapy group were orally given capecitabine (1,000 mg/m2, twice daily for 14 days, days 1-14) and intravenous oxaliplatin (130 mg/m2 on day 1) for 2 cycles. Radiotherapy was performed with a total of 45 Gy administered in 25 sessions for 5 weeks. Patients in the surgery group received only surgical intervention. RESULTS In the concurrent chemoradiotherapy group, the overall response rate was 55.6% (20/36), tumor control rate was 100% and a pathological complete response was achieved in 16.7% (6/36). The entire chemoradiotherapy group had R0 resections as did 80% of the surgery group (32/40) (P < 0.05). In the concurrent chemoradiotherapy group, 6 patients developed grade 3 side effects. Treatment was either discontinued or the dose adjusted. Major hematological side effects in the chemoradiotherapy group included leukopenia, neutropenia, anemia and thrombocytopenia. Nonhematological side effects included nausea, vomiting and appetite loss. Chemoradiotherapy-related death was not observed. CONCLUSIONS Concurrent neoadjuvant chemoradiotherapy administration increased the rate of R0 resection and demonstrated favorable safety in patients with Siewert II or III adenocarcinoma at the gastroesophageal junction. These results support the use of neoadjunctive chemoradiotherapy in the treatment of adenocarcinoma of the gastroesophageal junction.
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Sun Z, Nussbaum DP, Speicher PJ, Czito BG, Tyler DS, Blazer DG. Neoadjuvant radiation therapy does not increase perioperative morbidity among patients undergoing gastrectomy for gastric cancer. J Surg Oncol 2015; 112:46-50. [PMID: 26179329 DOI: 10.1002/jso.23957] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 06/05/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND Neoadjuvant radiation therapy (RT) as a component of the multimodality treatment of gastric cancer has demonstrated promising results. Data regarding its effect on perioperative safety are limited. METHODS Adults undergoing gastrectomy for gastric cancer in the 2005-2011 National Surgical Quality Improvement Program were included. Groups were defined by neoadjuvant RT use, and then propensity-matched based on preoperative variables. Multivariable logistic regression was performed to assess neoadjuvant RT as an independent predictor of outcomes. RESULTS Among 2,764 patients identified, 55 (2.0%) were treated with neoadjuvant RT. Patients who received neoadjuvant RT were more likely to have received preoperative chemotherapy and steroids, and experienced weight loss (all P < 0.01). After matching, however, there were no preoperative differences. At time of surgery, total (vs. partial) gastrectomy was more common among patients who underwent neoadjuvant RT (70.9 vs. 46.7%, P < 0.01), and operative time was longer (290 vs. 236 min, P < 0.01). There were no differences in overall complications (23.6 vs. 29.7%, P = 0.49) or 30-day mortality (3.6 vs. 3.6%, P = 0.99). CONCLUSIONS Neoadjuvant RT was not associated with increased morbidity or mortality following resection for gastric cancer. These findings support the ongoing investigation of neoadjuvant RT as part of the multidisciplinary management of resectable gastric cancer.
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Affiliation(s)
- Zhifei Sun
- Department of Surgery, Duke University, Durham, North Carolina
| | | | - Paul J Speicher
- Department of Surgery, Duke University, Durham, North Carolina
| | - Brian G Czito
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - Douglas S Tyler
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas
| | - Dan G Blazer
- Department of Surgery, Duke University, Durham, North Carolina
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Adjuvant Chemoradiation Therapy in Gastric Cancer: Critically Reviewing the Past and Visualizing the Next Step Forward. Gastroenterol Res Pract 2015; 2015:650846. [PMID: 26101524 PMCID: PMC4460248 DOI: 10.1155/2015/650846] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 05/10/2015] [Accepted: 05/12/2015] [Indexed: 02/07/2023] Open
Abstract
Gastric cancer remains one of the most common malignancies worldwide. Despite the significant advances in surgical treatment and multimodality strategies, prognosis has modestly improved over the last two decades. Locoregional relapse remains one of the main issues and the combined chemoradiation treatment seems to be one of the preferred approaches. However, more than ten years after the hallmark INT-0116 trial, minimal progress has been made both in terms of effectiveness and toxicity. Moreover, new regimens added to combined therapy failed to prove favourable results. Herein, we attempt a thorough literature review comparing pros and cons of all relative studies and potential bias, targeting well-designed future approaches.
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Fu T, Bu ZD, Li ZY, Zhang LH, Wu XJ, Wu AW, Shan F, Ji X, Dong QS, Ji JF. Neoadjuvant chemoradiation therapy for resectable esophago-gastric adenocarcinoma: a meta-analysis of randomized clinical trials. BMC Cancer 2015; 15:322. [PMID: 25928286 PMCID: PMC4415228 DOI: 10.1186/s12885-015-1341-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 04/22/2015] [Indexed: 12/15/2022] Open
Abstract
Background The efficacy and safety of preoperative chemoradiation therapy (CRT) for advanced esophago-gastric adenocarcinoma are still in question, and the prognosis of these patients is poor. Methods We systematically searched electronic databases from January 1990 to July 2014. The primary outcome was overall survival. The secondary outcomes were a R0 resection rate, positive rate of lymph node metastasis, postoperative recurrence rate, pathological complete response (pCR) rate and perioperative mortality. Overall survival was measured with a hazard ratio (HR), while other secondary outcomes were measured with an odds ratio (OR). Results Seven randomized controlled trials (RCTs) including 1085 patients were searched and, of these, 869 had adenocarcinoma. Patients receiving preoperative CRT had a longer overall survival (HR 0.74; 95% confidence interval (CI) 0.63–0.88), higher likelihood of R0 resection and greater chance of pCR, while they had a lower likelihood of lymph node metastasis and postoperative recurrence. The difference of perioperative mortality was non-significant. In addition, the result of the comparison between preoperative CRT and preoperative chemotherapy (CT) in two RCTs was non-significant. Conclusion Patients with resectable esophago-gastric adenocarcinoma can gain a survival advantage from preoperative CRT. However, limited to the number of RCTs, the effect of adding radiotherapy to preoperative CT separately is still uncertain and more high-quality prospective trials are needed.
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Affiliation(s)
- Tao Fu
- Department of gastrointestinal surgery, Peking University Cancer Hospital & Institute, Haidian District Fuchengmen Road No. 52, Beijing, 100142, China.
| | - Zhao-De Bu
- Department of gastrointestinal surgery, Peking University Cancer Hospital & Institute, Haidian District Fuchengmen Road No. 52, Beijing, 100142, China.
| | - Zi-Yu Li
- Department of gastrointestinal surgery, Peking University Cancer Hospital & Institute, Haidian District Fuchengmen Road No. 52, Beijing, 100142, China.
| | - Lian-Hai Zhang
- Department of gastrointestinal surgery, Peking University Cancer Hospital & Institute, Haidian District Fuchengmen Road No. 52, Beijing, 100142, China.
| | - Xiao-Jiang Wu
- Department of gastrointestinal surgery, Peking University Cancer Hospital & Institute, Haidian District Fuchengmen Road No. 52, Beijing, 100142, China.
| | - Ai-Wen Wu
- Department of gastrointestinal surgery, Peking University Cancer Hospital & Institute, Haidian District Fuchengmen Road No. 52, Beijing, 100142, China.
| | - Fei Shan
- Department of gastrointestinal surgery, Peking University Cancer Hospital & Institute, Haidian District Fuchengmen Road No. 52, Beijing, 100142, China.
| | - Xin Ji
- Department of gastrointestinal surgery, Peking University Cancer Hospital & Institute, Haidian District Fuchengmen Road No. 52, Beijing, 100142, China.
| | - Qiu-Shi Dong
- Department of gastrointestinal surgery, Peking University Cancer Hospital & Institute, Haidian District Fuchengmen Road No. 52, Beijing, 100142, China.
| | - Jia-Fu Ji
- Department of gastrointestinal surgery, Peking University Cancer Hospital & Institute, Haidian District Fuchengmen Road No. 52, Beijing, 100142, China.
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Preoperative treatment with radiochemotherapy for locally advanced gastroesophageal junction cancer and unresectable locally advanced gastric cancer. Radiol Oncol 2015; 49:163-72. [PMID: 26029028 PMCID: PMC4387993 DOI: 10.2478/raon-2014-0027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 05/19/2014] [Indexed: 12/12/2022] Open
Abstract
Background. To purpose of the study was to analyze the results of preoperative radiochemotherapy in patients with unresectable gastric or locoregionally advanced gastroesophageal junction (GEJ) cancer treated at a single institution. Patients and methods. Between 1/2004 and 6/2012, 90 patients with locoregionally advanced GEJ or unresectable gastric cancer were treated with preoperative radiochemotherapy at the Institute of Oncology Ljubljana. Planned treatment schedule consisted of induction chemotherapy with 5-fluorouracil and cisplatin, followed by concomitant radiochemotherapy four weeks later. Three-dimensional conformal external beam radiotherapy was delivered by dual energy (6 and 15 MV) linear accelerator in 25 daily fractions of 1.8 Gy in 5 weeks with two additional cycles of chemotherapy repeated every 28 days. Surgery was performed 4–6 weeks after completing radiochemotherapy. Following the surgery, multidisciplinary advisory team reassessed patients for the need of adjuvant chemotherapy. The primary endpoints were histopathological R0 resection rate and pathological response rate. The secondary endpoints were toxicity of preoperative radiochemotherapy and survival. Results. Treatment with preoperative radiochemotherapy was completed according to the protocol in 84 of 90 patients (93.3%). Twenty patients (22.2%) did not undergo the surgery because of the disease progression, serious comorbidity, poor performance status or still unresectable tumour. In 13 patients (14.4%) only exploration was performed because the tumour was assessed as unresectable or diffuse peritoneal carcinomatosis was established. Fifty-seven patients (63.4%) underwent surgery with the aim of complete removal of the tumour. Radical resection was achieved in 50 (55.6%) patients and the remaining seven (7.8%) patients underwent non-radical surgery (R1 in five and R2 in two patients). In this group of patients (n = 57), pathological complete response of tumour was achieved in five patients (5.6% of all treated patients or 8.8% of all operated patients). Down-staging was recorded in 49 patients (86%), in one patient (1.8%) the stage after radiochemotherapy was unchanged while in seven patients (12.3%) the pathological stage was higher than clinical, mainly due to higher pN stage. No death was recorded during preoperative radiochemotherapy. Most grade 3 and 4 toxicities were due to vomiting, nausea and bone marrow suppression (granulocytopenia). Twenty-six (45.6%) patients died due to GEJ or gastric carcinoma, one died because of septic shock following the surgery and a reason for two deaths was unknown. Twenty-eight patients (49.1%) were disease free at the time of analysis, while 29 patients (50.9%) developed the recurrence, mostly as distant metastases. At two years, locoregional control, disease-free survival, disease-specific survival and overall survival were 82.9%, 43.9%, 56.9% and 53.9%, respectively. Conclusions. Preoperative radiochemotherapy was feasible in our group of patients and had acceptable toxicity. Majority of patients achieved down-staging, allowing greater proportion of radical resections (R0), which are essential for patients’ cure.
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Chen S, Zou Z, Chen F, Huang Z, Li G. A meta-analysis of fast track surgery for patients with gastric cancer undergoing gastrectomy. Ann R Coll Surg Engl 2015. [PMID: 25519256 DOI: 10.1308/003588414x13946184903649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION This meta-analysis evaluated the safety and efficacy of fast track surgery (FTS) for patients with gastric cancer undergoing gastrectomy. METHODS Randomised controlled trials (RCTs) published between 1 January 1995 and 21 June 2013 comparing FTS with conventional perioperative care for patients with gastric cancer undergoing gastrectomy were identified in the PubMed, Embase™ and Cochrane Library databases, and were analysed systematically using RevMan software (Nordic Cochrane Centre, Copenhagen, Denmark). RESULTS Seven RCTs (524 patients) were analysed. Compared with conventional perioperative care, FTS treatment with/without laparoscopy was associated with shorter postoperative hospitalisation, less hospitalisation expenditure (both p<0.00001), less pain and better quality of life. Short-term morbidity and readmission rates did not differ between treatments. No incidents of death occurred during the short-term follow-up period. CONCLUSIONS In patients with gastric cancer undergoing gastrectomy, the FTS pathway reduces the length and cost of postoperative hospitalisation while maintaining short-term morbidity, readmission and mortality rates comparable with those of conventional care.
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Affiliation(s)
- S Chen
- Zhujiang Hospital, Southern Medical University, Guangzhou, China
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Chen S, Zou Z, Chen F, Huang Z, Li G. A meta-analysis of fast track surgery for patients with gastric cancer undergoing gastrectomy. Ann R Coll Surg Engl 2015; 97:3-10. [PMID: 25519256 PMCID: PMC4473895 DOI: 10.1308/rcsann.2015.97.1.3] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2014] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION This meta-analysis evaluated the safety and efficacy of fast track surgery (FTS) for patients with gastric cancer undergoing gastrectomy. METHODS Randomised controlled trials (RCTs) published between 1 January 1995 and 21 June 2013 comparing FTS with conventional perioperative care for patients with gastric cancer undergoing gastrectomy were identified in the PubMed, Embase™ and Cochrane Library databases, and were analysed systematically using RevMan software (Nordic Cochrane Centre, Copenhagen, Denmark). RESULTS Seven RCTs (524 patients) were analysed. Compared with conventional perioperative care, FTS treatment with/without laparoscopy was associated with shorter postoperative hospitalisation, less hospitalisation expenditure (both p<0.00001), less pain and better quality of life. Short-term morbidity and readmission rates did not differ between treatments. No incidents of death occurred during the short-term follow-up period. CONCLUSIONS In patients with gastric cancer undergoing gastrectomy, the FTS pathway reduces the length and cost of postoperative hospitalisation while maintaining short-term morbidity, readmission and mortality rates comparable with those of conventional care.
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Affiliation(s)
- S Chen
- Zhujiang Hospital, Southern Medical University, Guangzhou, China
- S Chen and Z Zou contributed equally to this work and should be considered as joint first authors
| | - Z Zou
- Nanfang Hospital, Southern Medical University, Guangzhou, China
- S Chen and Z Zou contributed equally to this work and should be considered as joint first authors
| | - F Chen
- Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Z Huang
- Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - G Li
- Zhujiang Hospital, Southern Medical University, Guangzhou, China
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Yu YJ, Sun WJ, Lu MD, Wang FH, Qi DS, Zhang Y, Li PH, Huang H, You T, Zheng ZQ. Efficacy of docetaxel combined with oxaliplatin and fluorouracil against stage III/IV gastric cancer. World J Gastroenterol 2014; 20:18413-18419. [PMID: 25561810 PMCID: PMC4277980 DOI: 10.3748/wjg.v20.i48.18413] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Revised: 09/15/2014] [Accepted: 10/21/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the clinical efficacy and toxic effects of neoadjuvant chemotherapy using docetaxel combined with oxaliplatin and fluorouracil for treating stage III/IV gastric cancer.
METHODS: A total of 53 stage III/IV gastric cancer patients were enrolled into the study and treated with neoadjuvant chemotherapy. Two of the cases were excluded. The program was as follows: 75 mg/m2 docetaxel and 85 mg/m2 oxaliplatin on day 1 and 1500 mg/m2 fluorouracil on days 1 to 3 for three weeks.
RESULTS: The tumour changes, postoperative remission rate, changes in the symptoms and adverse reactions were observed. The overall clinical efficacy (complete remission + partial remission) of the neoadjuvant chemotherapy was 62.7%. R0 radical resection was performed on 60.8% of the patients, with a remission rate (pathological complete response + pathological subtotal response + pathological partial response) of 74.2%. The Karnofksy score improved in 42 cases. The toxicity reactions mostly included myelosuppression, followed by gastrointestinal mucosal lesions, nausea, vomiting and diarrhoea.
CONCLUSION: Neoadjuvant chemotherapy consisting of docetaxel combined with oxaliplatin and fluorouracil is effective for stage III/IV gastric cancer. However, the treatment is associated with a high incidence of bone marrow suppression, which should be managed clinically.
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Saedi HS, Mansour-Ghanaei F, Joukar F, Shafaghi A, Shahidsales S, Atrkar-Roushan Z. Neoadjuvant chemoradiotherapy in non-cardia gastric cancer patients--does it improve survival? Asian Pac J Cancer Prev 2014; 15:8667-71. [PMID: 25374187 DOI: 10.7314/apjcp.2014.15.20.8667] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Survival rates after resection of advanced gastric cancer are extremely poor. An increasing number of patients with gastric carcinomas (GC) are therefore being treated with preoperative chemotherapy. We evaluated 36 month survival rate of GC patients that were treated by adding a neoadjuvant chemoradiotherapy before gastrostomy. MATERIALS AND METHODS Patients with stage II or III gastric adenocarcinomas were enrolled. The patients divided into two groups: (A) Neoadjuvant group that received concurrent chemoradiation before surgery (4,500 cGy of radiation at 180 cGy per day plus chemotherapy with cisplatin and 5-fluorouracil, in the first and the end four days of radiotherapy). Resection was attempted 5 to 6 weeks after end of chemoradiotherapy. (B) Adjuvant group that received concurrent chemo-radiation after surgical resection. RESULTS Two (16.7%) patients out of 12 patients treated with neoadjuvant chemo-radiotherapy and 5 (38.5%) out of 13 in the surgery group survived after 36 months. These rates were not significantly different with per protocol and intention-to-treat analysis. The median survival time of patients in group A and B were 13.4 and 21.6 months , respectively, again not significantly different. Survival was significantly greater in patients with well differentiated adenocarcinoma in group B than in group A (p<0.004). CONCLUSIONS According to this study we suggest surgery then chemoradiotherapy for patients with well differentiated gastric adenocarcinoma rather than other approaches. Additional studies with greater sample size and accurate matching relying on cancer molecular behavior are recommended.
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Affiliation(s)
- Hamid Saeidi Saedi
- Radiation Oncology, Gastrointestinal and Liver Diseases Research Center (GLDRC), Guilan University of Medical Sciences Rasht, Iran E-mail :
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Sun LB, Zhao GJ, Ding DY, Song B, Hou RZ, Li YC. Comparison between better and poorly differentiated locally advanced gastric cancer in preoperative chemotherapy: a retrospective, comparative study at a single tertiary care institute. World J Surg Oncol 2014; 12:280. [PMID: 25200958 PMCID: PMC4177253 DOI: 10.1186/1477-7819-12-280] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 09/02/2014] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Gastric cancer is the third leading cause of cancer-related mortality in China, and the long-term survival for locally advanced gastric cancer is very poor. Simple surgery cannot yield an ideal result because of the high recurrence rate after tumor resection. Preoperative chemotherapy could help to reduce tumor volume, improve the R0 resection rate (no residual tumor after surgery), and decrease the risk of local tumor recurrence. The aim of this study was to evaluate the influence of pathological differentiation in the effect of preoperative chemotherapy for patients with locally advanced gastric cancer. METHODS Patients with locally advanced gastric cancer (n = 32) received preoperative chemotherapy under the XELOX (capecitabine plus oxaliplatin) regimen. According to pathological examination, patients' tumors were classified into better (well and moderate) and poorly differentiated (lower differentiated and undifferentiated) groups, and the clinical response rate, type of gastrectomy, and negative tumor residual rate were compared between the two groups of patients. Morphological changes and toxic reactions were monitored after chemotherapy. RESULTS The results showed that the clinical response rate in the better differentiated group was significantly higher than that in the poorly differentiated group (100% versus 25%, P = 0.000). The partial gastrectomy rate in the better differentiated group was significantly higher than that in the poorly differentiated group (87.5% versus 25% P = 0.000). A significant shrinking of tumor and necrosis of tumor tissues caused by chemotherapy could be observed. CONCLUSIONS In conclusion, the better differentiated group with locally advanced gastric cancer is suitable for preoperative chemotherapy under the XELOX regimen, and as a result of effective preoperative chemotherapy, much more gastric tissue can be preserved for the better differentiated group.
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Affiliation(s)
- Li-Bo Sun
- >Department of Gastrointestinal Surgery, China-Japan Union Hospital, Jilin University, No. 126, Xiantai Street, Changchun, 130033 China
| | - Guo-Jie Zhao
- >Department of Gastrointestinal Surgery, China-Japan Union Hospital, Jilin University, No. 126, Xiantai Street, Changchun, 130033 China
| | - Da-Yong Ding
- >Department of Gastrointestinal Surgery, China-Japan Union Hospital, Jilin University, No. 126, Xiantai Street, Changchun, 130033 China
| | - Bin Song
- >Department of Gastrointestinal Surgery, China-Japan Union Hospital, Jilin University, No. 126, Xiantai Street, Changchun, 130033 China
| | - Rui-Zhi Hou
- >Department of Gastrointestinal Surgery, China-Japan Union Hospital, Jilin University, No. 126, Xiantai Street, Changchun, 130033 China
| | - Yong-Chao Li
- >Department of Gastrointestinal Surgery, China-Japan Union Hospital, Jilin University, No. 126, Xiantai Street, Changchun, 130033 China
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