Level I evidence in support of perioperative chemotherapy for operable gastric cancer: sufficient for wide clinical use?

Clinical management of gastric cancer: results of a multicentre survey

Background

The National Comprehensive Cancer Network clinical practice guidelines in oncology-gastric cancer guidelines have been widely used to provide appropriate recommendations for the treatment of patients with gastric cancer. The aim of this study was to examine the adherence of surgical oncologists, medical oncologists, and radiation oncologists' to the recommended guidelines.

Methods

A questionnaire asking the treatment options for gastric cancer cases was sent to 394 Chinese oncology specialists, including surgical oncologists, medical oncologists, and radiation oncologists working in hospitals joined in The Western Cooperative Gastrointestinal Oncology Group of China. The questionnaire involved a series of clinical scenarios regarding the interpretation of surgery, neoadjuvant, adjuvant, and advanced treatment planning of gastric cancer.

Results

Analysis of 358 respondents (91%) showed variations between each specialization and from the recommended guidelines in the management approaches to specific clinical scenarios. The majority of specialists admitted that less than 50% of patients received multidisciplinary evaluation before treatment. The participants gave different responses to questions involving adjuvant, neoadjuvant, and advanced settings, compared to the recommended guidelines.

Conclusions

These results highlight the heterogeneity of the treatment of gastric cancer. Surgical oncologists, medical oncologists, and radiation oncologists are not adhering to the recommended guidelines.

The extent of lymph node dissection for gastric cancer: a critical appraisal

The extent of lymphadenectomy during therapeutic gastrectomy for gastric cancer remains a protracted and controversial issue. While traditionally extended lymphadenectomy is performed in Eastern Asia, limited lymphadenectomy is advocated by most western surgeons. Two large western randomized trials, meta-analyses and a recent systematic review were unable to demonstrate overall benefit from extended lymphadenectomy. In this review, the currently available data on this topic are critically evaluated, while ongoing studies and future perspective are discussed.

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.

Feasibility and accuracy of second-look laparoscopy after gastrectomy for gastric cancer

BACKGROUND

A better method for detecting early peritoneal progression is needed. This study evaluated the feasibility and accuracy of second-look laparoscopy for patients with gastric cancer treated using systemic chemotherapy after gastrectomy.

METHODS

Second-look laparoscopy was conducted for patients who had no clinical evidence of distant metastases but had peritoneal metastases or positive peritoneal cytology results without visible metastatic disease at initial surgery, patients who underwent systemic chemotherapy over a 6-month period after surgery, and patients who had no clinical evidence of disease based on imaging study after completion of primary chemotherapy.

RESULTS

Between November 2004 and April 2008, 21 patients underwent second-look laparoscopy. At the initial surgery, 13 of these patients underwent total gastrectomy and 8 patients underwent distal gastrectomy. One or two sheets of adhesion barrier were received by 18 patients. The median interval between initial surgery and second-look laparoscopy was 9.8 months (range, 6.6-17.5 months). All second-look procedures were completed laparoscopically, and no patients required conversion to laparotomy. None of the 21 patients experienced postlaparoscopy complications. Whereas 12 patients showed no pathologic evidence of disease, 9 patients showed disease at second-look laparoscopy. There was a significant difference in median survival between the groups with negative and positive results (p = 0.017). The median survival for the negative group has not been determined. All the patients in the positive group received further chemotherapy while showing a good performance status (PS). Six patients were PS 0, and 3 patients were PS 1. The median survival time for this group was 10.1 months.

CONCLUSIONS

Second-look laparoscopy was a safe and promising approach to reassessment of peritoneal disease for patients with gastric cancer. The incidence of complications was low, particularly in this group of patients, all of whom had undergone prior gastrectomy.

7-Year survival results of perioperative chemotherapy with epidoxorubicin, etoposide, and cisplatin (EEP) in locally advanced resectable gastric cancer: up-to-date analysis of a phase-II study

BACKGROUND

Perioperative chemotherapy is considered an effective treatment option for patients with gastric carcinoma. We report the results after a 7-year follow-up of a study aimed at evaluating a perioperative chemotherapy protocol in a group of patients with locally advanced gastric cancer (LAGC).

METHODS

Between February 1996 and May 2000, 24 patients with LAGC underwent D2-gastrectomy after three preoperative cycles of chemotherapy (Epidoxorubicin, Etoposide, Cisplatinum). Three further cycles were planned after surgery. Differences among groups were evaluated using the chi-square test. Survival rate was calculated after a 7-year follow-up, and differences were assessed using the log-rank test. Multivariate analysis was performed using the Cox proportional hazard model.

RESULTS

A total of 24 patients received preoperative chemotherapy and underwent surgical resection. Of these, 17 (71%) received postoperative treatment. The main toxicity was grade 3-4 neutropenia. Curative resection (R0) was achieved in 83.3% of patients. No pathologic complete responses were documented, but tumor downstaging was obtained in 10 of 24 patients (41.7%). Overall median survival was 40 months, and 7-year survival rate was 46%. At univariate and multivariate analysis, R0 resection and tumor diameter were the most important prognostic factors.

CONCLUSION

Long-term results in our series show a survival benefit for LAGC patients treated by perioperative chemotherapy and D2-gastrectomy when compared with previously studied controls who had surgery with postoperative chemotherapy alone. The high rate and prognostic impact of R0 resection in this study stressed the role of the therapy during the preoperative phase.