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Yu Z, Tu H, Qiu S, Dong X, Zhang Y, Ma C, Li P. Multidisciplinary treatment for locally advanced gastric cancer: A systematic review and network meta-analysis. J Minim Access Surg 2023; 19:335-347. [PMID: 37282430 PMCID: PMC10449051 DOI: 10.4103/jmas.jmas_170_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 01/10/2023] [Accepted: 03/27/2023] [Indexed: 06/08/2023] Open
Abstract
Introduction This study aimed to evaluate the efficacy of multidisciplinary treatment for patients with locally advanced gastric cancer (LAGC) who underwent radical gastrectomy. Patients and Methods Randomised controlled trials (RCTs) comparing the effectiveness of surgery alone, adjuvant chemotherapy (CT), adjuvant radiotherapy (RT), adjuvant chemoradiotherapy (CRT), neoadjuvant CT, neoadjuvant RT, neoadjuvant CRT, perioperative CT and hyperthermic intraperitoneal chemotherapy (HIPEC) for LAGC were searched. Overall survival (OS), disease-free survival (DFS), recurrence and metastasis, long-term mortality, adverse events (grade ≥3), operative complications and R0 resection rate were used as outcome indicators for meta-analysis. Results Forty-five RCTs with 10077 participants were finally analysed. Adjuvant CT had higher OS (hazard ratio [HR] = 0.74, 95% credible interval [CI] = 0.66-0.82) and DFS (HR = 0.67, 95% CI = 0.60-0.74) than surgery-alone group. Perioperative CT (odds ratio [OR] = 2.56, 95% CI = 1.19-5.50) and adjuvant CT (OR = 0.48, 95% CI = 0.27-0.86) both had more recurrence and metastasis than HIPEC + adjuvant CT, while adjuvant CRT tended to have less recurrence and metastasis than adjuvant CT (OR = 1.76, 95% CI = 1.29-2.42) and even adjuvant RT (OR = 1.83, 95% CI = 0.98-3.40). Moreover, the incidence of mortality in HIPEC + adjuvant CT was lower than that in adjuvant RT (OR = 0.28, 95% CI = 0.11-0.72), adjuvant CT (OR = 0.45, 95% CI = 0.23-0.86) and perioperative CT (OR = 2.39, 95% CI = 1.05-5.41). Analysis of adverse events (grade ≥3) showed no statistically significant difference between any two adjuvant therapy groups. Conclusion A combination of HIPEC with adjuvant CT seems to be the most effective adjuvant therapy, which contributes to reducing tumour recurrence, metastasis and mortality - without increasing surgical complications and adverse events related to toxicity. Compared with CT or RT alone, CRT can reduce recurrence, metastasis and mortality but increase adverse events. Moreover, neoadjuvant therapy can effectively improve the radical resection rate, but neoadjuvant CT tends to increase surgical complications.
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Affiliation(s)
- Zhiyuan Yu
- School of Medicine, Nankai University, Nankai District, Tianjin, China
- Medical School of Chinese PLA, Haidian District, Beijing, China
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Haidian District, Beijing, China
| | - Huaiyu Tu
- Medical School of Chinese PLA, Haidian District, Beijing, China
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Haidian District, Beijing, China
| | - Shuzhong Qiu
- Medical School of Chinese PLA, Haidian District, Beijing, China
| | - Xiaoyu Dong
- Medical School of Chinese PLA, Haidian District, Beijing, China
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Haidian District, Beijing, China
| | - Yonghui Zhang
- Medical School of Chinese PLA, Haidian District, Beijing, China
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Haidian District, Beijing, China
| | - Chao Ma
- Medical School of Chinese PLA, Haidian District, Beijing, China
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Haidian District, Beijing, China
| | - Peiyu Li
- School of Medicine, Nankai University, Nankai District, Tianjin, China
- Medical School of Chinese PLA, Haidian District, Beijing, China
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Haidian District, Beijing, China
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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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Kim DW, Lee G, Hong TS, Li G, Horick NK, Roeland E, Keane FK, Eyler C, Drapek LC, Ryan DP, Allen JN, Berger D, Parikh AR, Mullen JT, Klempner SJ, Clark JW, Wo JY. Neoadjuvant versus Postoperative Chemoradiotherapy is Associated with Improved Survival for Patients with Resectable Gastric and Gastroesophageal Cancer. Ann Surg Oncol 2021; 29:242-252. [PMID: 34480285 DOI: 10.1245/s10434-021-10666-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 08/01/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND The optimal timing of chemoradiotherapy (CRT) for patients with localized gastric cancer remains unclear. This study aimed to compare the survival outcomes between neoadjuvant and postoperative CRT for patients with gastric and gastroesophageal junction (GEJ) cancer. METHODS This retrospective study analyzed 152 patients with gastric (42%) or GEJ (58%) adenocarcinoma who underwent definitive surgical resection and received either neoadjuvant or postoperative CRT between 2005 and 2017 at the authors' institution. The primary end point of the study was overall survival (OS). RESULTS The median follow-up period was 37.5 months. Neoadjuvant CRT was performed for 102 patients (67%) and postoperative CRT for 50 patients (33%). The patients who received neoadjuvant CRT were more likely to be male and to have a GEJ tumor, positive lymph nodes, and a higher clinical stage. The median radiotherapy (RT) dose was 50.4 Gy for neoadjuvant RT and 45.0 Gy for postoperative RT (p < 0.001). The neoadjuvant CRT group had a pathologic complete response (pCR) rate of 26% and a greater rate of R0 resection than the postoperative CRT group (95% vs. 76%; p = 0.002). Neoadjuvant versus postoperative CRT was associated with a lower rate of any grade 3+ toxicity (10% vs. 54%; p < 0.001). The multivariable analysis of OS showed lower hazards of death to be independently associated neoadjuvant versus postoperative CRT (hazard ratio [HR] 0.57; 95% confidence interval [CI] 0.36-0.91; p = 0.020) and R0 resection (HR 0.50; 95% CI 0.27-0.90; p = 0.021). CONCLUSIONS Neoadjuvant CRT was associated with a longer OS, a higher rate of R0 resection, and a lower treatment-related toxicity than postoperative CRT. The findings suggest that neoadjuvant CRT is superior to postoperative CRT in the treatment of gastric and GEJ cancer.
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Affiliation(s)
- Daniel W Kim
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Grace Lee
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Guichao Li
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Nora K Horick
- Massachusetts General Hospital Biostatistics Center, Boston, MA, USA
| | - Eric Roeland
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Florence K Keane
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Christine Eyler
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Lorraine C Drapek
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - David P Ryan
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Jill N Allen
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - David Berger
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Aparna R Parikh
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - John T Mullen
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Sam J Klempner
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Jeffrey W Clark
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA.
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Rausei S, Bali CD, Lianos GD. Neoadjuvant chemotherapy for gastric cancer. Has the time to decelerate the enthusiasm passed us by? Semin Oncol 2020; 47:355-360. [PMID: 32758372 DOI: 10.1053/j.seminoncol.2020.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 07/08/2020] [Accepted: 07/08/2020] [Indexed: 11/11/2022]
Abstract
Neoadjuvant therapy for locally advanced gastric cancer is a treatment option well recognized in international guidelines. However, neither completed randomized trials nor ongoing studies (will) offer definitive answers about the efficacy of neoadjuvant therapy. With extensive experience confirming the safety and some efficacy for this approach most current studies are focused on identifying the best preoperative treatment regimen. We try to clarify if is really the time to slow down the enthusiasm about neoadjuvant approach.
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Affiliation(s)
- Stefano Rausei
- Department of Surgery, ASST Valle Olona, Gallarate Varese, Italy..
| | - Christina D Bali
- Department of Surgery, University Hospital of Ioannina & University of Ioannina, Ioannina, Greece
| | - Georgios D Lianos
- Department of Surgery, University Hospital of Ioannina & University of Ioannina, Ioannina, Greece
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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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