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1
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Matheus GTFU, de Souza Wagner PH, Taumaturgo JAC, Lam SJ, de Moraes FCA. Preoperative Radiotherapy in Patients with Gastric and Gastro-Oesophageal Cancer: A Systematic Review and Meta-analysis. J Gastrointest Cancer 2025; 56:84. [PMID: 40123010 DOI: 10.1007/s12029-025-01204-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2025] [Indexed: 03/25/2025]
Abstract
BACKGROUND Gastric (GC) and gastroesophageal junction (GEJ) cancers are among the most prevalent digestive cancers, characterized by a poor prognosis, particularly in advanced stages, where the 5-year survival rate remains below 20%. While surgery is still the standard treatment, its limited ability to lower recurrence rates highlights the necessity for effective perioperative therapies. In this context, Radiotherapy (RT) and chemoradiotherapy (CRT) have been investigated for their potential to improve tumor control, pathologic complete response (pCR), and overall survival (OS) in advanced GC. This systematic review and meta-analysis aimed to assess the efficacy and safety of preoperative RT/CRT on key clinical outcomes in patients with GC, focusing on pathologic complete response (pCR), overall survival (OS), and postoperative complications, such as anastomotic leaks and postoperative mortality. METHODS A systematic search of PubMed, Embase, and Web of Science databases was conducted for randomized controlled trials and single-arm studies comparing preoperative RT/CRT with chemotherapy or surgery alone. Outcomes were pooled using risk ratios (RRs) or hazard ratios (HRs) with 95% confidence intervals (CIs), and heterogeneity was assessed using I2 statistics. Furthermore, quality assessment was performed using RoB 2 and ROBINS-I tools. We also utilized tools to enhance the interpretation and understanding of the meta-analysis results, including GRADE, the leave-one-out method, Baujat and Doi plots. RESULTS Ten studies including 6 RCTs and 4 single-arm studies, comprising 2,138 patients were included. CRT significantly improved pCR rates compared to control groups (RR 2.72; 95% CI 1.89-3.92; p < 0.000001; I2 = 0%), with a pCR rate of 21% in single-arm analysis. No statistical significance was observed in the hazard ratio analysis for OS (HR 0.84; 95% CI 0.65-1.10; p = 0.209; I2 = 67%), including the subgroup analyses at three (RR 1.15; 95% CI 0.93-1.43; p = 0.183; I2 = 70%) and five years (RR 1.23; 95% CI 1.00-1.51; p = 0.051; I2 = 58%). Moreover, the rates for anastomotic leaks (RR 0.86; 95% CI 0.66-1.14; p = 0.294; I2 = 0%) and postoperative mortality (RR 0.88; 95% CI 0.46-1.70; p = 0.71; I2 = 25%) showed no significant differences between groups, with low event rates in single-arm studies, 7% and 3%, respectively. CONCLUSION Preoperative CRT significantly improves pCR rates, highlighting its potential as a valuable strategy in tumor downstaging. However, it does not enhance survival outcomes, while notably, it does not increase surgical complications. Future studies incorporating biomarkers and standardized protocols are essential to refine patient selection, ensuring optimized treatment strategies and maximizing clinical benefits.
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Affiliation(s)
| | | | | | - Shi Juin Lam
- Anhembi Morumbi University, Piracicaba, 13425-380, Brazil
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2
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Lee G, Strickland MR, Wo JY. Role of Preoperative Radiation Therapy for Resectable Gastric Cancer. J Gastrointest Cancer 2024; 55:584-598. [PMID: 38353901 DOI: 10.1007/s12029-023-00985-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2023] [Indexed: 06/20/2024]
Abstract
PURPOSE While surgery is the primary curative treatment for resectable gastric and gastroesophageal junction (GEJ) cancer, rates of locoregional and distant recurrence remain high with surgery alone, especially in more advanced disease. Multimodal approaches with perioperative therapy including chemotherapy and/or radiation therapy (RT) have thus evolved as ways to reduce the rates of disease recurrence and improve survival outcomes. This review article provides a comprehensive literature review on the role of preoperative RT for resectable gastric and GEJ cancer. METHODS A literature review on the role of preoperative RT for resectable gastric and GEJ cancer was conducted. RESULTS Preoperative RT has the potential to facilitate tumor downstaging and improved R0 resection, allowing for better locoregional control and thereby survival. For resectable locally advanced GEJ cancer, preoperative chemoradiotherapy (CRT) is currently a standard of care option along with perioperative chemotherapy, based on evidence from randomized trials. In resectable gastric cancer, however, the role of preoperative CRT is less defined with no randomized data to date, although phase II single-arm studies have shown promising results. Current standard of care for gastric cancer remains perioperative chemotherapy, with consideration for preoperative CRT in select cases. CONCLUSION Results from ongoing and future randomized controlled trials are expected to help define the role of preoperative CRT compared to perioperative chemotherapy alone as well as postoperative CRT for gastric and GEJ cancer.
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Affiliation(s)
- Grace Lee
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthew R Strickland
- Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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3
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Ling Q, Huang ST, Yu TH, Liu HL, Zhao LY, Chen XL, Liu K, Chen XZ, Yang K, Hu JK, Zhang WH. Optimal timing of surgery for gastric cancer after neoadjuvant chemotherapy: a systematic review and meta-analysis. World J Surg Oncol 2023; 21:377. [PMID: 38037067 PMCID: PMC10690980 DOI: 10.1186/s12957-023-03251-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/13/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Following neoadjuvant chemotherapy, surgical resection is one of the most preferred treatment options for locally advanced gastric cancer patients. However, the optimal time interval between chemotherapy and surgery is unclear. This review aimed to identify the optimal time interval between neoadjuvant chemotherapy and surgery for advanced gastric cancer. METHODS Beginning on November 12, 2022, we searched the PubMed, Cochrane Library, Web of Science databases, and Embase.com databases for relevant English-language research. Two authors independently screened the studies, assessed their quality, extracted the data, and analyzed the results. The primary goal was to investigate the relationship between the time interval to surgery (TTS) and long-term survival outcomes for patients. This study has been registered with PROSPERO (CRD42022365196). RESULTS After an initial search of 4880 articles, the meta-analysis review ultimately included only five retrospective studies. Ultimately, this meta-analysis included 1171 patients, of which 411 patients had TTS of < 4 weeks, 507 patients had TTS of 4-6 weeks, and 253 patients had TTS of > 6 weeks. In survival analysis, patients with TTS of > 6 weeks had poorer overall survival outcomes than patients with TTS of 4-6 weeks (HR = 1.34, 95% CI: 1.03-1.75, P = 0.03). No significant differences were found in terms of disease-free survival the groups. CONCLUSION Based on the current clinical evidence, patients with locally advanced gastric cancer may benefit better with a TTS of 4-6 weeks; however, this option still needs additional study.
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Grants
- No. 21PJ043 1. Medical Science and Technique Project of Health Commission of Sichuan Province
- No. 21PJ043 1. Medical Science and Technique Project of Health Commission of Sichuan Province
- No. 21PJ043 1. Medical Science and Technique Project of Health Commission of Sichuan Province
- No. 21PJ043 1. Medical Science and Technique Project of Health Commission of Sichuan Province
- No. 21PJ043 1. Medical Science and Technique Project of Health Commission of Sichuan Province
- No. 21PJ043 1. Medical Science and Technique Project of Health Commission of Sichuan Province
- No. 21PJ043 1. Medical Science and Technique Project of Health Commission of Sichuan Province
- No. 21PJ043 1. Medical Science and Technique Project of Health Commission of Sichuan Province
- No. 21PJ043 1. Medical Science and Technique Project of Health Commission of Sichuan Province
- No. 21PJ043 1. Medical Science and Technique Project of Health Commission of Sichuan Province
- No. 21PJ043 1. Medical Science and Technique Project of Health Commission of Sichuan Province
- No. 23NSFSC1611 2. Natural Science Foundation of Sichuan Province
- No. 23NSFSC1611 2. Natural Science Foundation of Sichuan Province
- No. 23NSFSC1611 2. Natural Science Foundation of Sichuan Province
- No. 23NSFSC1611 2. Natural Science Foundation of Sichuan Province
- No. 23NSFSC1611 2. Natural Science Foundation of Sichuan Province
- No. 23NSFSC1611 2. Natural Science Foundation of Sichuan Province
- No. 23NSFSC1611 2. Natural Science Foundation of Sichuan Province
- No. 23NSFSC1611 2. Natural Science Foundation of Sichuan Province
- No. 23NSFSC1611 2. Natural Science Foundation of Sichuan Province
- No. 23NSFSC1611 2. Natural Science Foundation of Sichuan Province
- No. 23NSFSC1611 2. Natural Science Foundation of Sichuan Province
- No. 2020HXBH162 3. Post-Doctor Research Project, West China Hospital, Sichuan University
- No. 2020HXBH162 3. Post-Doctor Research Project, West China Hospital, Sichuan University
- No. 2020HXBH162 3. Post-Doctor Research Project, West China Hospital, Sichuan University
- No. 2020HXBH162 3. Post-Doctor Research Project, West China Hospital, Sichuan University
- No. 2020HXBH162 3. Post-Doctor Research Project, West China Hospital, Sichuan University
- No. 2020HXBH162 3. Post-Doctor Research Project, West China Hospital, Sichuan University
- No. 2020HXBH162 3. Post-Doctor Research Project, West China Hospital, Sichuan University
- No. 2020HXBH162 3. Post-Doctor Research Project, West China Hospital, Sichuan University
- No. 2020HXBH162 3. Post-Doctor Research Project, West China Hospital, Sichuan University
- No. 2020HXBH162 3. Post-Doctor Research Project, West China Hospital, Sichuan University
- No. 2020HXBH162 3. Post-Doctor Research Project, West China Hospital, Sichuan University
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Affiliation(s)
- Qi Ling
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Shi-Ting Huang
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Tian-Hang Yu
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Han-Lin Liu
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Lin-Yong Zhao
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xiao-Long Chen
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Kai Liu
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xin-Zu Chen
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Kun Yang
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Jian-Kun Hu
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China.
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, China.
| | - Wei-Han Zhang
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China.
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, China.
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Rosa F, Schena CA, Laterza V, Quero G, Fiorillo C, Strippoli A, Pozzo C, Papa V, Alfieri S. The Role of Surgery in the Management of Gastric Cancer: State of the Art. Cancers (Basel) 2022; 14:cancers14225542. [PMID: 36428634 PMCID: PMC9688256 DOI: 10.3390/cancers14225542] [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: 09/27/2022] [Revised: 11/04/2022] [Accepted: 11/09/2022] [Indexed: 11/15/2022] Open
Abstract
Surgery still represents the mainstay of treatment of all stages of gastric cancer (GC). Surgical resections represent potentially curative options in the case of early GC with a low risk of node metastasis. Sentinel lymph node biopsy and indocyanine green fluorescence are novel techniques which may improve the employment of stomach-sparing procedures, ameliorating quality of life without compromising oncological radicality. Nonetheless, the diffusion of these techniques is limited in Western countries. Conversely, radical gastrectomy with extensive lymphadenectomy and multimodal treatment represents a valid option in the case of advanced GC. Differences between Eastern and Western recommendations still exist, and the optimal multimodal strategy is still a matter of investigation. Recent chemotherapy protocols have made surgery available for patients with oligometastatic disease. In this context, intraperitoneal administration of chemotherapy via HIPEC or PIPAC has emerged as an alternative weapon for patients with peritoneal carcinomatosis. In conclusion, the surgical management of GC is still evolving together with the multimodal strategy. It is mandatory for surgeons to be conscious of the current evolution of the surgical management of GC in the era of multidisciplinary and tailored medicine.
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Affiliation(s)
- Fausto Rosa
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Carlo Alberto Schena
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Vito Laterza
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Correspondence:
| | - Giuseppe Quero
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Claudio Fiorillo
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Antonia Strippoli
- Medical Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Carmelo Pozzo
- Medical Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Valerio Papa
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Sergio Alfieri
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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5
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Hu J, Yang Y, Ma Y, Ning Y, Chen G, Liu Y. Survival benefits from neoadjuvant treatment in gastric cancer: a systematic review and meta-analysis. Syst Rev 2022; 11:136. [PMID: 35788246 PMCID: PMC9252040 DOI: 10.1186/s13643-022-02001-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/08/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Surgery is the main treatment option for patients with local gastric cancer. However, surgery alone is usually not sufficient for stomach cancer patients, and combined therapies are recommended for these patients. In recent studies, some preoperative treatments have shown benefits. However, the treatment selection is still uncertain because previous studies failed to obtain a statistically significant difference between preoperative chemotherapy and preoperative chemoradiotherapy. Therefore, we plan to perform a systematic review and meta-analysis to compare the benefits among these preoperative treatments. METHODS/DESIGN This review includes randomized controlled trials with or without blinding as well as published studies, high-quality unpublished studies, full articles and meeting abstracts with an English context if sufficient results were provided for analysis. Data sources include the Cochrane Central Register of Controlled Trials, Embase, MEDLINE, major relevant international conferences and manual screening of references. Patients with a diagnosis of resectable primary gastric or EGJ adenocarcinoma (stage II or higher) who underwent surgery alone or preoperative treatment followed by surgery and who were pathologically confirmed as proposed by the AJCC 2017 guidelines without age, sex, race, subtypes of adenocarcinoma and molecular pathology limitations will be included. The following three interventions will be included: surgery alone, neoadjuvant chemistry followed by surgery and neoadjuvant chemoradiotherapy followed by surgery. All-cause mortality, overall survival (OS, the time interval from diagnosis to death) and/or progression-free survival (PFS, the time interval from diagnosis to disease progression or death from any cause) will be defined as major results of concern. The clinical and pathological response rate (according to RECIST and tumour regression score), R0 resection rate, quality of life and grade 3 or above adverse events (according to the National Cancer Institute Common Terminology Criteria for Adverse Events, NCI-CTCAE) will be defined as the secondary outcomes. DISCUSSION The aim of this systematic review is to compare the benefits of different preoperative treatments for patients with locoregional stomach cancer. This systematic review will improve the understanding of the relative efficacy of these treatment options by providing the latest evidence on the efficacy of various treatment options in the management of gastric cancer patients and may guide clinical practice. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD4202123718.
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Affiliation(s)
- Jianwen Hu
- Department of General Surgery, Peking University First Hospital, Beijing, 100034, People's Republic of China
| | - Yanpeng Yang
- Department of General Surgery, Peking University First Hospital, Beijing, 100034, People's Republic of China
| | - Yongchen Ma
- Endoscopy Center, Peking University First Hospital, Beijing, 100034, People's Republic of China
| | - Yingze Ning
- Department of General Surgery, Peking University First Hospital, Beijing, 100034, People's Republic of China
| | - Guowei Chen
- Department of General Surgery, Peking University First Hospital, Beijing, 100034, People's Republic of China.
| | - Yucun Liu
- Department of General Surgery, Peking University First Hospital, Beijing, 100034, People's Republic of China.
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6
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Misra S, Yeshala SK, Singh S, Singh RK, Maria Das KJ, Kumar S, Kumar S. A Pilot Study of Perioperative Cisplatin-Capecitabine Chemotherapy With Preoperative Chemoradiation for Resectable Gastric Cancers. Am J Clin Oncol 2021; 44:475-481. [PMID: 34183522 DOI: 10.1097/coc.0000000000000844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The standard of care for resectable gastric cancers (GCs) includes perioperative chemotherapy (CT) or postoperative chemo/chemoradiotherapy (CRT) strategies. Poor treatment compliance postsurgery suggests that intensified surgical adjuvant treatment is more likely deliverable preceding surgery and, therefore, the safety and efficacy of perioperative cisplatin-capecitabine (CX) with preoperative chemoradiation (preopCRT) were ascertained. MATERIALS AND METHODS Between January 2017 and December 2018, 28 potentially resectable locally advanced GC patients were offered neoadjuvant CT-2 cycles of CX at 3-weekly intervals, followed by preopCRT 45 Gy/25 fractions/5 weeks and concurrent capecitabine, followed by surgical resection and 3 adjuvant cycles of CX. RESULTS Neoadjuvant CT was commenced in 28 patients (100%), preopCRT in 18 patients (64%), and surgery performed in 13 patients (46%). At each treatment step, decreasing patient numbers were due mainly to disease progression (12 [43%]) or other reasons, including (3 [11%]) from treatment-related toxicity. The R0 resection rate was 92% (12/13); a median of 18 nodes was obtained after D2 nodal clearance in 92% (12/13). There were 20%/4%/4% grade 3/4/5 toxicities. The median radiotherapy dose/duration was 45 Gy/5.4 weeks. Adjuvant CT was started in 11 patients (39%) and the third cycle was received by 7 patients (25%). No tumor (ypT0N0) was noted in 23% of the operated patients (3/13), or 11% of the intention-to-treat population (3/28). The median, 1-year, and 2-year survivals were 12 months, 53%, and 32%, respectively. CONCLUSIONS Intensified preoperative treatment is doable in relatively unselected advanced GC patients in real-world settings of a public-sector hospital from a low-middle-income country. Disease progression during preoperative therapy allows patients destined for early clinical evidence of disease dissemination to avoid futile surgery, as opposed to a surgery-first strategy, without an overt increase in surgical morbidity or mortality, with encouraging R0 resection rates.
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Affiliation(s)
| | | | | | - Rajneesh K Singh
- Gastrosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences
| | | | | | - Shaleen Kumar
- Departments of Radiotherapy
- Superspeciality Cancer Institute and Hospital, CG City, Lucknow, Uttar Pradesh, India
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7
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Ludmir EB, Das P. Shifting sands: the role of radiotherapy for patients with gastric and gastroesophageal adenocarcinoma. Transl Gastroenterol Hepatol 2021; 6:50. [PMID: 34423171 PMCID: PMC8343419 DOI: 10.21037/tgh.2020.03.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 03/11/2020] [Indexed: 12/26/2022] Open
Abstract
Gastric adenocarcinoma, a leading cause of cancer-related mortality worldwide, is treated primarily with surgical resection in the non-metastatic setting. However, the optimal role and sequencing of adjunctive therapies, including radiotherapy (RT) as well as systemic therapy, remains unclear. A complex milieu of trials spanning several decades has evaluated different treatment strategies for gastric cancer, including the role of RT. In this review, we summarize the trial-level evidence for the diverse gastric cancer treatment paradigms. Despite initial success, postoperative RT has not shown a clear benefit in modern prospective studies in the setting of more aggressive surgical nodal dissection. On the other hand, the role of preoperative RT in optimizing oncologic outcomes for gastric cancer patients remains relatively under-explored; ongoing trials assessing preoperative RT aim to illuminate the optimal treatment strategy for non-metastatic gastric cancer patients.
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Affiliation(s)
- Ethan B Ludmir
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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8
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Lee TC, Wima K, Morris MC, Johnston ME, Shah SA, Ahmad SA, Patel SH, Wilson GC. Lack of National Adoption of Evidence-Based Treatment for Resectable Gastric Adenocarcinoma. J Gastrointest Surg 2021; 25:36-47. [PMID: 33201456 PMCID: PMC7670838 DOI: 10.1007/s11605-020-04868-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 11/06/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Level 1 evidence for multimodal treatment of resectable gastric adenocarcinoma from the Intergroup 0116 (2001) and MAGIC (2006) trials demonstrated survival benefit of adjuvant chemoradiation (CRT) and perioperative chemotherapy, respectively. We evaluated the adoption of evidence-based treatment in the post-MAGIC era and its impact on survival. METHODS A total of 7058 patients with resectable gastric adenocarcinoma undergoing definitive surgical resection between 2004 and 2015 were analyzed using the National Cancer Database. RESULTS Over the study period, the proportion of patients receiving adjuvant CRT decreased from 19.1% to 9.1%, while perioperative chemotherapy increased from 1.9% to 28.6%. Utilization of perioperative chemotherapy surpassed adjuvant CRT in 2011. Evidence-based treatment (either perioperative chemotherapy or adjuvant CRT) had better overall survival (OS) than other treatments for clinical stage II-III patients (p < 0.05). On multivariate analysis of the whole study period, evidence-based treatments were associated with better OS (HR 0.67 [0.60-0.74], p < 0.05). Only 360/1262 (28.5%) patients in the perioperative chemotherapy group completed postoperative therapy, which was associated with improved OS (p < 0.05). For clinical stage III patients (n = 2402), only 806 (33.6%) received evidence-based treatment, while 487 (22.2%) underwent surgery alone. On multivariate analysis of these patients between 2010 and 2015, both perioperative chemotherapy (HR 0.49 [0.35-0.68]) and adjuvant CRT (HR 0.31 [0.21-0.44]) were associated with better OS than surgery alone (p < 0.05). CONCLUSIONS Since the INT-0116 and MAGIC trials, utilization of evidence-based treatments for resectable gastric adenocarcinoma has increased, with perioperative chemotherapy surpassing adjuvant CRT as the preferred practice. However, overall utilization of these regimens remains quite low nationally despite association with improved OS.
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Affiliation(s)
- Tiffany C. Lee
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, OH USA ,grid.24827.3b0000 0001 2179 9593Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML 0558, Cincinnati, OH 45267 USA
| | - Koffi Wima
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, OH USA ,grid.24827.3b0000 0001 2179 9593Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML 0558, Cincinnati, OH 45267 USA
| | - Mackenzie C. Morris
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, OH USA ,grid.24827.3b0000 0001 2179 9593Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML 0558, Cincinnati, OH 45267 USA
| | - Michael E. Johnston
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, OH USA ,grid.24827.3b0000 0001 2179 9593Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML 0558, Cincinnati, OH 45267 USA
| | - Shimul A. Shah
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, OH USA ,grid.24827.3b0000 0001 2179 9593Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML 0558, Cincinnati, OH 45267 USA
| | - Syed A. Ahmad
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, OH USA ,grid.24827.3b0000 0001 2179 9593Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML 0558, Cincinnati, OH 45267 USA
| | - Sameer H. Patel
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, OH USA ,grid.24827.3b0000 0001 2179 9593Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML 0558, Cincinnati, OH 45267 USA
| | - Gregory C. Wilson
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Cincinnati, OH USA ,grid.24827.3b0000 0001 2179 9593Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML 0558, Cincinnati, OH 45267 USA
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9
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Slagter AE, Vollebergh MA, Jansen EPM, van Sandick JW, Cats A, van Grieken NCT, Verheij M. Towards Personalization in the Curative Treatment of Gastric Cancer. Front Oncol 2020; 10:614907. [PMID: 33330111 PMCID: PMC7734340 DOI: 10.3389/fonc.2020.614907] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/02/2020] [Indexed: 12/12/2022] Open
Abstract
Gastric cancer is the fifth most common cancer worldwide and has a high mortality rate. In the last decades, treatment strategy has shifted from an exclusive surgical approach to a multidisciplinary strategy. Treatment options for patients with resectable gastric cancer as recommended by different worldwide guidelines, include perioperative chemotherapy, pre- or postoperative chemoradiotherapy and postoperative chemotherapy. Although gastric cancer is a heterogeneous disease with respect to patient-, tumor-, and molecular characteristics, the current standard of care is still according to a one-size-fits-all approach. In this review, we discuss the background of the different treatment strategies in resectable gastric cancer including the current standard, the specific role of radiotherapy, and describe the current areas of research and potential strategies for personalization of therapy.
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Affiliation(s)
- Astrid E Slagter
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Marieke A Vollebergh
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Edwin P M Jansen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | - Annemieke Cats
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | - Marcel Verheij
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands.,Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, Netherlands
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10
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Zhu Z, Gong YB, Xu HM. Neoadjuvant therapy strategies for advanced gastric cancer: Current innovations and future challenges. Chronic Dis Transl Med 2020; 6:147-157. [PMID: 32908968 PMCID: PMC7451732 DOI: 10.1016/j.cdtm.2020.03.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Indexed: 12/15/2022] Open
Abstract
Gastric cancer, which has a high incidence and poor prognosis, remains a therapeutic challenge. Recently, neoadjuvant therapy has attracted increasing attention due to high recurrence rate and low survival rate after resection in most patients with advanced stage. Clinical trials show that neoadjuvant approaches confer a significant survival advantage for resectable locally advanced gastric cancer. The specific advantages of chemoradiotherapy compared with chemotherapy have not been clarified; optimal regimens and cycles, particularly in the preoperative setting, should be studied further; and trials aimed at determining the role of targeted and immunological therapies should be conducted.
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Affiliation(s)
- Zhi Zhu
- Department of Surgical Oncology, The First Hospital of China Medical University, Shenyang, Liaoning 110001, China
| | - Ying-Bo Gong
- Department of Surgical Oncology, The First Hospital of China Medical University, Shenyang, Liaoning 110001, China
| | - Hui-Mian Xu
- Department of Surgical Oncology, The First Hospital of China Medical University, Shenyang, Liaoning 110001, China
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11
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Roy AC, Shapiro J, Burge M, Karapetis CS, Pavlakis N, Segelov E, Chau I, Lordick F, Chen LT, Barbour A, Tebbutt N, Price T. Management of early-stage gastro-esophageal cancers: expert perspectives from the Australasian Gastrointestinal Trials Group (AGITG) with invited international faculty. Expert Rev Anticancer Ther 2020; 20:305-324. [PMID: 32202178 DOI: 10.1080/14737140.2020.1746185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Introduction: A multimodal approach in operable early-stage oesophago-gastric (OG) cancer has evolved in the last decade, leading to improvement in overall outcomes.Areas covered: A review of the published literature and conference abstracts was undertaken on the topic of optimal adjunctive chemotherapy or chemoradiotherapy in early-stage OG cancers. This review article focuses on the current evidence pertaining to neoadjuvant and perioperative strategies in curable OG cancers including the evolving landscape of immunotherapy and targeted drugs in this setting.Expert commentary: Adjunctive therapies in the form of preoperative chemo-radiotherapy (CRT) or chemotherapy and perioperative chemotherapy over surgery alone improve outcomes in patients with operable OG cancer. Although there are variations in practice around the world, a multi-disciplinary approach to patient care is of paramount importance. Immunotherapy and on treatment functional imaging are two examples of emerging strategies to improve the outcome for early-stage patients. A better understanding of the molecular biology of this disease may help overcome the problem of tumor heterogeneity and enable more rationally designed and targeted therapeutic interventions in the future.
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Affiliation(s)
- Amitesh C Roy
- Flinders Centre for Innovation in Cancer, Flinders University, Bedford Park, Australia
| | | | - Matt Burge
- Department of Cancer Care Services, Royal Brisbane Hospital, University Of Queensland, Herston, Australia
| | - Christos S Karapetis
- Flinders Centre for Innovation in Cancer, Flinders University, Bedford Park, Australia
| | - Nick Pavlakis
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, Australia
| | - Eva Segelov
- Department of Medical Oncology, Monash University and Monash Health, Melbourne, Australia
| | - Ian Chau
- Department of Medical Oncology, Royal Marsden Hospital, Institute of Cancer Research, Surrey, London, UK
| | - Florian Lordick
- Leipzig University Medical Centre, University Cancer Centre Leipzig, Leipzig, Germany
| | - Li-Tong Chen
- National Institute of Cancer Research, National Health Research Institutes, Tainan, Taiwan
| | - Andrew Barbour
- The University of Queensland Diamantina Institute, The University of Queensland, Woolloongabba, Australia
| | - Niall Tebbutt
- Department of Medical Oncology, Austin Health, Heidelberg, Australia
| | - Tim Price
- Queen Elizabeth Hospital, University of Adelaide, Adelaide, Australia
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12
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Sotoudeh M, Shirvani SI, Merat S, Ahmadbeigi N, Naderi M. MSLN (Mesothelin), ANTXR1 (TEM8), and MUC3A are the potent antigenic targets for CAR T cell therapy of gastric adenocarcinoma. J Cell Biochem 2018; 120:5010-5017. [PMID: 30260046 DOI: 10.1002/jcb.27776] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 09/06/2018] [Indexed: 12/31/2022]
Abstract
Gastric adenocarcinoma is usually diagnosed in late stages, necessitating the use of different therapeutic modalities. Currently, antibody-based therapies have also been approved through with limited clinical efficacy. Reinforcing antibody-based immunotherapy by using chimeric antigen receptor (CAR) T cells may enhance the approach. However, the cells can cause severe on-target and off-tumor toxicities owing to their higher sensitivity to low-level antigen expressions. To address the need for safe and reliable targets, we made a bioinformatics pipeline by which we screened overexpressed genes in the disease for off-tumor sites in many normal tissues. Our inspection showed that MSLN (Mesothelin), ANTXR1 (TEM8), and MUC3A are the probable targets of CAR T cell therapy in gastric adenocarcinoma. The proposed antigenic targets might respond to the need to simultaneously target multiple antigens in a tumor matrix to prevent resistance.
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Affiliation(s)
- Masoud Sotoudeh
- Liver and Pancreatobiliary Diseases Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran.,Digestive Diseases Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Iman Shirvani
- Cell-Based Therapies Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahin Merat
- Liver and Pancreatobiliary Diseases Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran.,Digestive Oncology Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Naser Ahmadbeigi
- Cell-Based Therapies Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahmood Naderi
- Cell-Based Therapies Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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13
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Zhang N, Fei Q, Gu J, Yin L, He X. Progress of preoperative and postoperative radiotherapy in gastric cancer. World J Surg Oncol 2018; 16:187. [PMID: 30213266 PMCID: PMC6137719 DOI: 10.1186/s12957-018-1490-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 09/05/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Gastric carcinoma, a highly common malignant tumor, is treated mainly by surgery. Meanwhile, radiotherapy is attracting increased attention as a crucial locoregional therapy. However, the application of radiotherapy in gastric carcinoma is still limited and radiation standards remain debatable. MAIN BODY The use of preoperative radiotherapy for treating gastroesophageal junction cancer has advanced. However, additional phase III clinical trials are needed to further verify the therapeutic value of preoperative radiotherapy for gastric cancer. Patients with D1 or D1 plus lymphadenectomy can benefit from postoperative radiotherapy obviously, and postoperative radiotherapy may be effective for patients with D2 lymphadenectomy with a high N stage. The target volume delineation of preoperative and postoperative radiotherapy should be based on clinical experience and the characteristics of lymphatic drainage. CONCLUSIONS With the advancement of radiotherapy technology, preoperative and postoperative radiotherapy are becoming increasingly accepted as important auxiliary treatments for gastric cancer.
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Affiliation(s)
- Nan Zhang
- Department of Radiation Oncology, Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research & Affiliated Cancer Hospital of Nanjing Medical University, Nanjing Medical University Affiliated Cancer Hospital, 42 Baiziting, Nanjing, 210009 Jiangsu China
| | - Qian Fei
- Department of Radiation Oncology, Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research & Affiliated Cancer Hospital of Nanjing Medical University, Nanjing Medical University Affiliated Cancer Hospital, 42 Baiziting, Nanjing, 210009 Jiangsu China
- The Fourth Clinical School of Nanjing Medical University, Nanjing, China
| | - Jiajia Gu
- Department of Radiation Oncology, Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research & Affiliated Cancer Hospital of Nanjing Medical University, Nanjing Medical University Affiliated Cancer Hospital, 42 Baiziting, Nanjing, 210009 Jiangsu China
| | - Li Yin
- Department of Radiation Oncology, Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research & Affiliated Cancer Hospital of Nanjing Medical University, Nanjing Medical University Affiliated Cancer Hospital, 42 Baiziting, Nanjing, 210009 Jiangsu China
- The Fourth Clinical School of Nanjing Medical University, Nanjing, China
| | - Xia He
- Department of Radiation Oncology, Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research & Affiliated Cancer Hospital of Nanjing Medical University, Nanjing Medical University Affiliated Cancer Hospital, 42 Baiziting, Nanjing, 210009 Jiangsu China
- The Fourth Clinical School of Nanjing Medical University, Nanjing, China
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14
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Cartwright E, Keane FK, Enzinger PC, Hong T, Chau I. Is There a Precise Adjuvant Therapy for Esophagogastric Carcinoma? Am Soc Clin Oncol Educ Book 2018; 38:280-291. [PMID: 30231360 DOI: 10.1200/edbk_200785] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Esophagogastric cancer remains a leading cause of cancer-related mortality worldwide. The prognosis for patients with locally advanced disease is poor and the majority of patients with operable tumors treated with surgery alone will have recurrent disease. A multimodal approach to treatment with adjunctive chemotherapy or chemoradiotherapy is therefore the standard of care for these patients. However, there is no global consensus on the optimal treatment strategy and international guidelines vary. National clinical trials inform local practice: neoadjuvant, perioperative, and adjuvant chemotherapy and radiotherapy combinations are all possible treatment options in the management of resectable esophagogastric cancer. A number of clinical trials are ongoing, which seek to directly compare multimodal treatment options and hope to provide clarity in this area. Furthermore, increased understanding of the molecular and genetic features of esophagogastric cancer may help to guide management of operable disease by determining optimal patient selection through identification of predictive biomarkers of response and the application of novel targeted agents.
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Affiliation(s)
- Elizabeth Cartwright
- From the Royal Marsden Hospital, London, United Kingdom; Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; Department of Medicine, Royal Marsden Hospital, Surrey, United Kingdom
| | - Florence K Keane
- From the Royal Marsden Hospital, London, United Kingdom; Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; Department of Medicine, Royal Marsden Hospital, Surrey, United Kingdom
| | - Peter C Enzinger
- From the Royal Marsden Hospital, London, United Kingdom; Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; Department of Medicine, Royal Marsden Hospital, Surrey, United Kingdom
| | - Theodore Hong
- From the Royal Marsden Hospital, London, United Kingdom; Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; Department of Medicine, Royal Marsden Hospital, Surrey, United Kingdom
| | - Ian Chau
- From the Royal Marsden Hospital, London, United Kingdom; Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; Department of Medicine, Royal Marsden Hospital, Surrey, United Kingdom
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15
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Vošmik M, Laco J, Sirák I, Dvořák J, Lochman P, Hodek M, Malá P, Rejchrt S, Repák R, Leško M, Ferko A, Ryška A, Melichar B, Petera J. Histopathologic Features are more Important Prognostic Factors than Primary Tumour Location in Gastro-oesophageal Adenocarcinoma Treated with Preoperative Chemoradiation and Surgery. Pathol Oncol Res 2018; 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] [MESH Headings] [Grants] [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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Affiliation(s)
- Milan Vošmik
- Department of Oncology and Radiotherapy, Charles University, Faculty of Medicine in Hradec Kralove and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic.
| | - Jan Laco
- The Fingerland Department of Pathology, Charles University, Faculty of Medicine in Hradec Kralove and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Igor Sirák
- Department of Oncology and Radiotherapy, Charles University, Faculty of Medicine in Hradec Kralove and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Josef Dvořák
- Department of Oncology and Radiotherapy, Charles University, Faculty of Medicine in Hradec Kralove and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Petr Lochman
- Faculty of Military Health Sciences, University of Defense, Hradec Kralove, Czech Republic
- Department of Surgery, Charles University, Faculty of Medicine in Hradec Kralove and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Miroslav Hodek
- Department of Oncology and Radiotherapy, Charles University, Faculty of Medicine in Hradec Kralove and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Petra Malá
- Department of Oncology and Radiotherapy, Charles University, Faculty of Medicine in Hradec Kralove and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Stanislav Rejchrt
- Second Department of Internal Medicine-Gastroenterology, Charles University, Faculty of Medicine in Hradec Kralove and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Rudolf Repák
- Second Department of Internal Medicine-Gastroenterology, Charles University, Faculty of Medicine in Hradec Kralove and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Michal Leško
- Department of Surgery, Charles University, Faculty of Medicine in Hradec Kralove and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Alexander Ferko
- Department of Surgery, Charles University, Faculty of Medicine in Hradec Kralove and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Aleš Ryška
- The Fingerland Department of Pathology, Charles University, Faculty of Medicine in Hradec Kralove and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Bohuslav Melichar
- Department of Oncology, Faculty of Medicine and Dentistry, Palacky University, and University Hospital Olomouc, Olomouc, Czech Republic
| | - Jiří Petera
- Department of Oncology and Radiotherapy, Charles University, Faculty of Medicine in Hradec Kralove and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
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16
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Zhou ML, Wang L, Wang JZ, Yang W, Hu R, Li GC, Sheng WQ, Zhang Z. Validation of the Memorial Sloan Kettering Cancer Center nomogram to predict disease-specific survival in a Chinese gastric cancer population receiving postoperative chemoradiotherapy after an R0 resection. Oncotarget 2018; 7:64757-64765. [PMID: 27588465 PMCID: PMC5323113 DOI: 10.18632/oncotarget.11665] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 08/11/2016] [Indexed: 12/26/2022] Open
Abstract
The widely validated Memorial Sloan Kettering Cancer Center (MSKCC) nomogram for gastric carcinoma (GC) was developed based on patients who received R0 resection only. The purpose of the current study was to assess the performance of this nomogram in Chinese patients who received postoperative chemoradiotherapy (CRT) after an R0 resection for GC. From 2006 to 2015, the clinical data of 150 eligible patients were retrospectively collected from the Fudan University Shanghai Cancer Center (FUSCC) and used for external validation. The nomogram was validated by means of the concordance index (CI) and a calibration plot. The CI for the nomogram was 0.657, which was lower than the CI of the nomogram for patients who received surgery alone (0.80). In the calibration plot, the gap between the observed and the predicted survival gradually increased as the predicted 5-year disease-specific survival (DSS) decreased. Thus the MSKCC nomogram for GC significantly underestimated the survival of patients in the FUSCC cohort, especially the survival of patients whose predicted 5-year DSS was less than 50%. The current study indicates the potential for the nomogram to be developed as an ideal tool to identify target patients for postoperative CRT.
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Affiliation(s)
- Meng-Long Zhou
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, PR China
| | - Lei Wang
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, 200032, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, PR China
| | - Jia-Zhou Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, PR China
| | - Wang Yang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, PR China
| | - Ran Hu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, PR China
| | - Gui-Chao Li
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, PR China
| | - Wei-Qi Sheng
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, 200032, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, PR China
| | - Zhen Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, PR China
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17
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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: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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18
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Becerra-Pedraza LC, Carlos NG, Carmona GRC, Martínez-Piña DA. Uncommon Initial Presentation of Gastric Cancer with Bone Metastases: a Case Report. J Gastrointest Cancer 2017; 50:334-337. [PMID: 29047043 DOI: 10.1007/s12029-017-0015-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Luis Cuitláhuac Becerra-Pedraza
- General Hospital of Morelia Dr. Miguel Silva, Morelia, Michoacán, Mexico. .,, Av. Insurgentes Sur. # 3877. Col Fama, Tlalpan, Mexico City, Mexico.
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19
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Zhou J, Wu X, Li G, Gao X, Zhai M, Chen W, Hu H, Tang Z. Prediction of radiosensitive patients with gastric cancer by developing gene signature. Int J Oncol 2017; 51:1067-1076. [PMID: 28902346 PMCID: PMC5592874 DOI: 10.3892/ijo.2017.4107] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Accepted: 07/31/2017] [Indexed: 12/20/2022] Open
Abstract
Adjuvant radiotherapy is an important clinical treatment for the majority of gastric cancer, a common cancer. However, radiotherapy is a double-edged sword. It is necessary to develop a method to predict radiosensitive patients who are most likely to benefit from radiotherapy. Using the publicly available data of gastric cancer from The Cancer Genome Atlas (TCGA), we developed a gene signature that predicts radiosensitive patients through estimating a new index, nominal HR (nHR) (HR product of sensitive genes), for each patient. In this study, we provided several results to validate our prediction. Cross-validation results showed that the predicted radiosensitive patients who received radiotherapy had significantly better survival than predicted radiosensitive patients who did not receive radiotherapy. After adjusting for other clinical factors, including age, sex, target therapy, histologic diagnosis, tumor stage, the benefit of radiotherapy on predicted radiosensitive patient remained significant. In addition, predicted radiosensitive patients who received radiotherapy had a significantly reduced rate of disease progression. Taken together, we have obtained a set of genes, to identify radiosensitive patients with gastric cancer. These genes may be potential biomarkers for diagnosis and treatment of gastric cancer, which could give new insight for revealing the underlying mechanism of radiosensitivity of gastric cancer.
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Affiliation(s)
- Jin Zhou
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Xiaoyu Wu
- Department of Surgical Oncology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu 210029, P.R. China
| | - Gang Li
- Department of General Surgery, Jiangsu Cancer Hospital, Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, Jiangsu 210009, P.R. China
| | - Xin Gao
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Min Zhai
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Weichang Chen
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Huagang Hu
- School of Nursing, Medical College of Soochow University, Suzhou, Jiangsu 215123, P.R. China
| | - Zaixiang Tang
- Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, and Center for Genetic Epidemiology and Genomics, Medical College of Soochow University, Suzhou, Jiangsu 215123, P.R. China
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20
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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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21
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Preoperative Chemotherapy for Gastric Cancer: Personal Interventions and Precision Medicine. BIOMED RESEARCH INTERNATIONAL 2016; 2016:3923585. [PMID: 28105420 PMCID: PMC5220419 DOI: 10.1155/2016/3923585] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 12/04/2016] [Indexed: 12/26/2022]
Abstract
In spite of the declining incidence of gastric cancer (GC) in recent years, the mortality rate is still high. The asymptomatic nature and nonspecific clinical manifestations combined with the lack of efficient screening programs delay the diagnosis of GC. Therefore, the prevalence of advanced gastric cancer (AGC) has prompted the need for aggressive and intensive treatment options. Among the various treatment options for AGC, surgery is still the mainstay. However, the efficacy of surgery alone is not established. Results from multiple randomized controlled trials suggest that preoperative chemotherapy is promising intervention for the treatment and management of AGC. The main objective of neoadjuvant chemotherapy is to downstage or control micrometastasis in resectable tumor before surgery. On the other hand, conversion chemotherapy refers to surgical treatment aiming at R0 resection after chemotherapy for originally nonresectable or marginally resectable tumors. Nevertheless, preoperative chemoradiotherapy is considered beneficial for AGC patients. Over the last few decades, the combination of chemotherapy and targeted therapy prior to surgery demonstrated great results for the treatment of AGC. The rapid developments in genomics and proteomics have heralded the era of precision medicine. The combination of preoperative chemotherapy and precision medicine may enhance survival in AGC patients.
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22
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Morita S, Fukagawa T, Fujiwara H, Katai H. Questionnaire survey regarding the current status of super-extended lymph node dissection in Japan. World J Gastrointest Oncol 2016; 8:707-714. [PMID: 27672429 PMCID: PMC5027026 DOI: 10.4251/wjgo.v8.i9.707] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 06/19/2016] [Accepted: 07/13/2016] [Indexed: 02/05/2023] Open
Abstract
AIM To verify the current status of super-extended lymph node dissection for advanced gastric cancer according to a questionnaire survey.
METHODS One-hundred and five institutions responded to the questionnaire. The survey included the following items: Number of experiences, whether performed prophylactically and/or therapeutically, whether preoperative chemotherapy was provided, number of preoperative chemotherapy rounds, and therapeutic options after chemotherapy.
RESULTS Eighty-seven of the 105 institutions (83%) had performed D3 gastrectomy in the past or continued to perform D3 gastrectomy at present. However, D3 gastrectomy was rarely performed prophylactically in clinical practice. Seventy-eight institutions (74%) indicated that preoperative chemotherapy with curative intent was required for patients suspected of having para-aortic node (PAN) metastases. After chemotherapy, a D3 gastrectomy was scheduled for patients with a complete or partial response, stable disease, and progressive disease at 36 (46%), 28 (36%), and 13 (17%) of the institutions, respectively.
CONCLUSION For patients with apparent PAN metastasis, a D3 gastrectomy is typically planned if a few courses of preoperative chemotherapy yield at least a stable disease condition.
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23
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Zhou ML, Kang M, Li GC, Guo XM, Zhang Z. Postoperative chemoradiotherapy versus chemotherapy for R0 resected gastric cancer with D2 lymph node dissection: an up-to-date meta-analysis. World J Surg Oncol 2016; 14:209. [PMID: 27502921 PMCID: PMC4977857 DOI: 10.1186/s12957-016-0957-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 07/20/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND This meta-analysis aims to provide more evidence on the role of postoperative chemoradiotherapy (CRT) for gastric cancer (GC) patients in Asian countries where D2 lymphadenectomy is prevalent. METHODS We conducted a systematic review of randomized controlled trials (RCTs), extracted data of survival and toxicities, and pooled data to evaluate the efficacy and toxicities of CRT compared with chemotherapy (CT) after D2 lymphadenectomy. RESULTS A total of 960 patients from four RCTs were selected. The results showed that postoperative CRT significantly reduced loco-regional recurrence rate (LRRR: RR = 0.50, 95 % CI = 0.34-0.74, P = 0.0005) and improved disease-free survival (DFS: HR = 0.73, 95 % CI = 0.60-0.89, P = 0.002). However, CRT did not affect distant metastasis rate (DMR: RR = 0.81, 95 % CI = 0.60-1.08, P = 0.15) and overall survival (OS: HR = 0.91, 95 % CI = 0.74-1.11, P = 0.34). The main grade 3-4 toxicities manifested no significant differences between the two groups. CONCLUSIONS Overall, CRT after D2 lymphadenectomy may reduce LRRR and prolong DFS. The role of postoperative CRT should be further investigated in the population with high risk of loco-regional recurrence.
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Affiliation(s)
- Meng-Long Zhou
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong An Rd, Shanghai, 200032, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, 270 Dong An Rd, Shanghai, 200032, PR China
| | - Mei Kang
- Institute of Clinical Epidemiology, Key Laboratory of Public Health Safety, Ministry of Education, School of Public Health, School of Public Health, Fudan University, 130 Dong An Rd, Shanghai, 200032, PR China
| | - Gui-Chao Li
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong An Rd, Shanghai, 200032, PR China.,Department of Oncology, Shanghai Medical College, Fudan University, 270 Dong An Rd, Shanghai, 200032, PR China
| | - Xiao-Mao Guo
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong An Rd, Shanghai, 200032, PR China. .,Department of Oncology, Shanghai Medical College, Fudan University, 270 Dong An Rd, Shanghai, 200032, PR China.
| | - Zhen Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong An Rd, Shanghai, 200032, PR China. .,Department of Oncology, Shanghai Medical College, Fudan University, 270 Dong An Rd, Shanghai, 200032, PR China.
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Badgwell B, Ajani J, Blum M, Ho L, Fournier K, Chiang YJ, Matamoros A, Das P, Mansfield P. Postoperative Morbidity and Mortality Rates are Not Increased for Patients with Gastric and Gastroesophageal Cancer Who Undergo Preoperative Chemoradiation Therapy. Ann Surg Oncol 2016; 23:156-162. [PMID: 26059652 DOI: 10.1245/s10434-015-4643-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Indexed: 01/09/2023]
Abstract
BACKGROUND This study aimed to determine whether postoperative morbidity and mortality rates increased after preoperative chemoradiation in patients who underwent gastrectomy. METHODS The medical records of 7404 patients with gastric or gastroesophageal cancer seen from January 1995 to August 2012 were reviewed to identify patients who underwent gastrectomy. χ (2) and logistic regression analysis were used to determine differences in the 90-day postoperative morbidity and mortality rates of patients who underwent upfront surgery (SURG), preoperative chemotherapy (CHEMO), or preoperative chemoradiation (CHEMOXRT). RESULTS Of the 500 patients included in this study, 200 underwent SURG, 65 had CHEMO, and 235 had CHEMOXRT. Respectively, 33, 43, and 58 % of these patients underwent total gastrectomy (p < 0.01). Resection of other organs was performed respectively in 19, 26, and 23 % of the patients (p = 0.37). Minor complications within 90 days (Clavien-Dindo 1 or 2) occurred for 41 % of the SURG patients, 43 % of the CHEMO patients, and 45 % of the CHEMOXRT patients (p = 0.68). Major complications or death within 90 days (Clavien-Dindo 3, 4, or 5) occurred for 21, 28, and 29 % of the patients, respectively (p = 0.15). The 90-day mortality (Clavien-Dindo 5) rates were 2 % for the SURG patients, 6 % for the CHEMO patients, and 3 % for the CHEMOXRT patients (p = 0.25). The median hospital stays were respectively 12, 12, and 13 days (p = 0.09). In the multivariate analysis, male sex, gastroesophageal junction cancer, total gastrectomy, and resection of other organs were associated with increased major morbidity and mortality rates, whereas preoperative therapy was not. CONCLUSIONS The CHEMOXRT patients had postoperative morbidity and mortality rates similar to those for the SURG and CHEMO patients.
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Affiliation(s)
- Brian Badgwell
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Jaffer Ajani
- Department of Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mariela Blum
- Department of Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Linus Ho
- Department of Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keith Fournier
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yi-Ju Chiang
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Aurelio Matamoros
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul Mansfield
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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25
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Biondi A, Lirosi MC, D’Ugo D, Fico V, Ricci R, Santullo F, Rizzuto A, Cananzi FCM, Persiani R. Neo-adjuvant chemo(radio)therapy in gastric cancer: Current status and future perspectives. World J Gastrointest Oncol 2015; 7:389-400. [PMID: 26690252 PMCID: PMC4678386 DOI: 10.4251/wjgo.v7.i12.389] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 07/03/2015] [Accepted: 10/15/2015] [Indexed: 02/05/2023] Open
Abstract
In the last 20 years, several clinical trials on neoadjuvant chemotherapy and chemo-radiotherapy as a therapeutic approach for locally advanced gastric cancer have been performed. Even if more data are necessary to define the roles of these approaches, the results of preoperative treatments in the combined treatment of gastric adenocarcinoma are encouraging because this approach has led to a higher rate of curative surgical resection. Owing to the results of most recent randomized phase III studies, neoadjuvant chemotherapy for locally advanced resectable gastric cancer has satisfied the determination of level I evidence. Remaining concerns pertain to the choice of the optimal therapy regimen, strict patient selection by accurate pre-operative staging, standardization of surgical procedures, and valid criteria for response evaluation. New well-designed trials will be necessary to find the best therapeutic approach in pre-operative settings and the best way to combine old-generation chemotherapeutic drugs with new-generation molecules.
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26
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Newton AD, Datta J, Loaiza-Bonilla A, Karakousis GC, Roses RE. Neoadjuvant therapy for gastric cancer: current evidence and future directions. J Gastrointest Oncol 2015; 6:534-43. [PMID: 26487948 DOI: 10.3978/j.issn.2078-6891.2015.047] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Although surgical resection remains the only potentially curative treatment for gastric cancer (GC), poor long-term outcomes with resection alone compel a multimodality approach to this disease. Multimodality strategies vary widely; while adjuvant approaches are typically favored in Asia and the United States (USA), a growing body of evidence supports neoadjuvant and/or perioperative strategies in locally advanced tumors. Neoadjuvant approaches are particularly attractive given the morbidity associated with surgical management of GC and the substantial risk of omission of adjuvant therapy. The specific advantages of chemoradiotherapy (CRT) compared to chemotherapy have not been well defined, particularly in the preoperative setting and trials aimed at determining the optimal elements and sequencing of therapy are underway. Future studies will also define the role of targeted and biologic therapies.
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Affiliation(s)
- Andrew D Newton
- 1 Department of Surgery, 2 Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jashodeep Datta
- 1 Department of Surgery, 2 Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Arturo Loaiza-Bonilla
- 1 Department of Surgery, 2 Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Giorgos C Karakousis
- 1 Department of Surgery, 2 Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Robert E Roses
- 1 Department of Surgery, 2 Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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27
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Badgwell B, Blum M, Estrella J, Chiang YJ, Das P, Matamoros A, Fournier K, Mansfield P, Ajani J. Predictors of Survival in Patients with Resectable Gastric Cancer Treated with Preoperative Chemoradiation Therapy and Gastrectomy. J Am Coll Surg 2015; 221:83-90. [PMID: 26002780 DOI: 10.1016/j.jamcollsurg.2015.04.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 02/19/2015] [Accepted: 04/06/2015] [Indexed: 01/30/2023]
Abstract
BACKGROUND The purpose of this study was to determine the overall survival (OS) of patients with resectable gastric cancer treated with preoperative chemoradiation therapy and gastrectomy. STUDY DESIGN The medical records of patients with gastric adenocarcinoma presenting to our institution (January 1995 to August 2012) were reviewed to identify patients who underwent diagnostic laparoscopy, preoperative chemoradiation, and gastrectomy. Associations between various clinicopathologic factors and OS were examined with Cox proportional hazards models. RESULTS Of 192 patients who met inclusion criteria, 103 (54%) required total gastrectomy. One hundred sixty-eight patients (88%) had an extended lymph node dissection, 26 (14%) had resection of adjacent organs, and 178 (93%) had an R0 resection. Median follow-up time for surviving patients was 4.2 years. Median OS for all patients was 5.8 years, and 5-year OS rate was 56%. Multivariable Cox regression model results identified variables associated with diminished OS including age ≥ 65 years (hazard ratio [HR] 1.62; 95% CI 1.05 to 2.51), male sex (HR 1.76; 95% CI 1.13 to 2.74), adjacent organ resection (HR 1.97; 95% CI 1.16 to 3.35), R1 status (HR 2.29; 95% CI 1.17 to 4.48), pathologic N1 stage (HR 1.92; 95% CI 1.24 to 2.98), N2 stage (HR 2.58; 95% CI 1.01 to 6.58), and N3 stage (HR 6.54; 95% CI 2.69 to 15.93). Five-year OS rates for patients with pathologic N0, N1, N2, and N3 disease were 67%, 42%, 43%, and 0%, respectively. CONCLUSIONS Patients with gastric cancer who undergo diagnostic laparoscopy, preoperative chemoradiation, and gastrectomy have a high frequency of obtaining an R0 resection and excellent OS rates. Nodal status after surgery remains an important determinant of OS.
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Affiliation(s)
- Brian Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Mariela Blum
- Department of Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeannelyn Estrella
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Aurelio Matamoros
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Keith Fournier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Paul Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jaffer Ajani
- Department of Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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28
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Chen H, Wu S, Kundra A, Aja Onu I, Gotlieb V, Wang JC. Gastric Perforation in a Patient Receiving Neoadjuvant Chemoradiotherapy. World J Oncol 2015; 6:383-386. [PMID: 28983335 PMCID: PMC5624666 DOI: 10.14740/wjon924w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2015] [Indexed: 12/21/2022] Open
Abstract
Perioperative chemoradiotherapy is considered to be one of the standards of care for early-stage gastric cancer, especially when it involves the esophagogastric junction or greater curvature. To date, there are no reported cases of gastrointestinal perforation in the literature, including many major clinical trials of adjuvant or neoadjuvant chemoradiotherapy for gastric cancer. It is important to recognize and manage this rare, but fatal complication in a timely manner. We report one case of gastrointestinal perforation in a gastric cancer patient undergoing neoadjuvant chemoradiotherapy with 5-fluorouracil and oxaliplatin. A 75-year-old man was diagnosed with stage IV gastric cancer (T4N1M0). We started neoadjuvant chemoradiotherapy with 5-fluorouracil and oxaliplatin. After he finished the first cycle, the patient presented to emergency room with severe abdominal pain of sudden onset. Computed tomography showed moderate pneumoperitoneum and perihepatic fluid. The patient expired 6 hours after he presented to emergency room.
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Affiliation(s)
- Hui Chen
- Division of Hematology/Oncology, Brookdale University Hospital Medical Center, Brooklyn, NY, USA
| | - Susan Wu
- Department of Pathology, South Nassau Communities Hospital, Oceanside, NY, USA
| | - Ajay Kundra
- Division of Hematology/Oncology, Brookdale University Hospital Medical Center, Brooklyn, NY, USA
| | - Iheanyichukwu Aja Onu
- Department of Gastroenterology, South Nassau Communities Hospital, Oceanside, NY, USA
| | - Vladimir Gotlieb
- Division of Hematology/Oncology, Brookdale University Hospital Medical Center, Brooklyn, NY, USA
| | - Jen C Wang
- Division of Hematology/Oncology, Brookdale University Hospital Medical Center, Brooklyn, NY, USA
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29
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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: 26] [Impact Index Per Article: 2.6] [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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Tanaka K, Mohri Y, Koike Y, Okugawa Y, Toiyama Y, Ohi M, Kobayashi M, Inoue Y, Araki T, Uchida K, Miki C, Kusunoki M. Molecular characteristics of residual cancer and stromal cells after chemoradiotherapy for gastric cancer: report of four cases. Clin Case Rep 2015; 2:165-72. [PMID: 25614804 PMCID: PMC4302618 DOI: 10.1002/ccr3.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 01/07/2014] [Accepted: 02/20/2014] [Indexed: 11/09/2022] Open
Abstract
KEY CLINICAL MESSAGE Four patients with gastric cancer underwent 5-fluorouracil and cisplatin-based chemoradiotherapy followed by surgery. Expression analysis of chemoradiosensitivity related genes in residual cancer using formalin-fixed paraffin-embedded specimens may be useful when determining a chemotherapy regimen for disease recurrence after chemoradiotherapy for gastric cancer.
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Affiliation(s)
- Koji Tanaka
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yasuhiko Mohri
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yuhki Koike
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yoshinaga Okugawa
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yuji Toiyama
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Masaki Ohi
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Minako Kobayashi
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yasuhiro Inoue
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Toshimitsu Araki
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Keiichi Uchida
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Chikao Miki
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Masato Kusunoki
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
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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: 2.8] [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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Wydmanski J, Grabinska K, Polanowski P, Namysl-Kaletka A, Kawczynski R, Kraszkiewicz M, Majewski W. Radiotherapy and chemoradiotherapy as a novel option for the treatment of locally advanced inoperable gastric adenocarcinoma: A phase II study. Mol Clin Oncol 2014; 2:1150-1154. [PMID: 25279214 DOI: 10.3892/mco.2014.348] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 06/23/2014] [Indexed: 12/12/2022] Open
Abstract
This phase II trial aimed to evaluate the tolerance and efficacy of radical radiotherapy or chemoradiotherapy in patients with primarily inoperable gastric cancer. The analysis was based on 13 patients with primarily inoperable gastric cancer. A total of 6 (46.2%) patients refused surgery and 7 (53.8%) had contraindications to anesthesia due to cardiological or respiratory reasons (4 and 3 patients, respectively). The treatment regimen consisted of radiotherapy and chemotherapy based on 5-fluorouracil. Half of the patients were not qualified to receive chemotherapy due to the presence of comorbidities. A total dose of 45 Gy was administered in 25 fractions. Of the 13 patients who started treatment, 12 (92.3%) completed radiotherapy. Local treatment response was observed in 6/12 patients (50%), with 5/12 (41.7%) displaying clinical complete response and 1/12 (8.3%) partial response. The 1- and 3-year overall survival rates and the median survival were 59 and 48% and 17.1 months, respectively. In conclusion, radical radiotherapy, either alone or in combination with chemotherapy, is safe for patients with inoperable locally advanced gastric cancer and may prolong survival.
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Affiliation(s)
- Jerzy Wydmanski
- Department of Radiotherapy, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, 44-101 Gliwice, Poland
| | - Kinga Grabinska
- Department of Radiotherapy, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, 44-101 Gliwice, Poland
| | - Pawel Polanowski
- Department of Radiotherapy, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, 44-101 Gliwice, Poland
| | - Agnieszka Namysl-Kaletka
- Department of Radiotherapy, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, 44-101 Gliwice, Poland
| | - Rafal Kawczynski
- Department of Radiotherapy, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, 44-101 Gliwice, Poland
| | - Malgorzata Kraszkiewicz
- Department of Radiotherapy, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, 44-101 Gliwice, Poland
| | - Wojciech Majewski
- Department of Radiotherapy, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, 44-101 Gliwice, Poland
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Trip AK, Poppema BJ, van Berge Henegouwen MI, Siemerink E, Beukema JC, Verheij M, Plukker JTM, Richel DJ, Hulshof MCCM, van Sandick JW, Cats A, Jansen EPM, Hospers GAP. Preoperative chemoradiotherapy in locally advanced gastric cancer, a phase I/II feasibility and efficacy study. Radiother Oncol 2014; 112:284-8. [PMID: 24856116 DOI: 10.1016/j.radonc.2014.05.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 04/29/2014] [Accepted: 05/01/2014] [Indexed: 12/16/2022]
Abstract
OBJECTIVES This study was initiated to investigate the feasibility and efficacy of preoperative radiotherapy with weekly paclitaxel and carboplatin in locally advanced gastric cancer. METHODS In a prospective study, patients with locally advanced gastric cancer stage IB-IV(M0) were treated with chemoradiotherapy followed by surgery 4-6 weeks after the last irradiation. Chemoradiotherapy consisted of radiation to a total dose of 45 Gy given in 25 fractions of 1.8 Gy, combined with concurrent weekly carboplatin and paclitaxel. RESULTS Between December 2007 and January 2012, 25 patients with cT3 (64%) or cT4 (36%) gastric cancer were included. One patient discontinued concurrent chemotherapy in the 4th week due to toxicity, but completed radiotherapy. Another patient discontinued chemoradiotherapy after the 3rd week due to progressive disease. Grade III adverse events of chemoradiotherapy were: gastrointestinal 12%, haematological 12% and other 8%. All patients, except one who developed progressive disease, were operated. Surgical complications were: general/infectious 48%, anastomotic leakage 12%, and bowel perforation 8%. Postoperative mortality was 4%. Microscopically radical resection rate was 72%. Pathological complete response rate was 16% and near complete response rate 24%. CONCLUSIONS In this study, preoperative chemoradiotherapy for patients with locally advanced gastric cancer was associated with manageable toxicity and encouraging pathological response rates.
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Affiliation(s)
- Anouk K Trip
- Department of Radiation Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Boelo J Poppema
- Department of Medical Oncology, University Medical Centre Groningen, The Netherlands
| | | | - Ester Siemerink
- Department of Internal Medicine, Ziekenhuisgroep Twente, Hengelo, The Netherlands
| | - Jannet C Beukema
- Department of Radiation Oncology, University Medical Centre Groningen, The Netherlands
| | - Marcel Verheij
- Department of Radiation Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - John T M Plukker
- Department of Surgical Oncology, University Medical Centre Groningen, The Netherlands
| | - Dick J Richel
- Department of Medical Oncology, Academic Medical Centre - University of Amsterdam, The Netherlands
| | - Maarten C C M Hulshof
- Department of Radiation Oncology, Academic Medical Centre - University of Amsterdam, The Netherlands
| | - Johanna W van Sandick
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Annemieke Cats
- Department of Gastroenterology and Hepatology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Edwin P M Jansen
- Department of Radiation Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Geke A P Hospers
- Department of Medical Oncology, University Medical Centre Groningen, The Netherlands.
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Pepek JM, Chino JP, Willett CG, Palta M, Blazer III DG, Tyler DS, Uronis HE, Czito BG. Preoperative chemoradiotherapy for locally advanced gastric cancer. Radiat Oncol 2013; 8:6. [PMID: 23286735 PMCID: PMC3552754 DOI: 10.1186/1748-717x-8-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Accepted: 12/28/2012] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND To examine toxicity and outcomes for patients treated with preoperative chemoradiotherapy (CRT) for gastric cancer. METHODS Patients with gastroesophageal (GE) junction (Siewert type II and III) or gastric adenocarcinoma who underwent neoadjuvant CRT followed by planned surgical resection at Duke University between 1987 and 2009 were reviewed. Overall survival (OS), local control (LC) and disease-free survival (DFS) were estimated using the Kaplan-Meier method. Toxicity was graded according to the Common Toxicity Criteria for Adverse Events version 4.0. RESULTS Forty-eight patients were included. Most (73%) had proximal (GE junction, cardia and fundus) tumors. Median radiation therapy dose was 45 Gy. All patients received concurrent chemotherapy. Thirty-six patients (75%) underwent surgery. Pathologic complete response and R0 resection rates were 19% and 86%, respectively. Thirty-day surgical mortality was 6%. At 42 months median follow-up, 3-year actuarial OS was 40%. For patients undergoing surgery, 3-year OS, LC and DFS were 50%, 73% and 41%, respectively. CONCLUSIONS Preoperative CRT for gastric cancer is well tolerated with acceptable rates of perioperative morbidity and mortality. In this patient cohort with primarily advanced disease, OS, LC and DFS rates in resected patients are comparable to similarly staged, adjuvantly treated patients in randomized trials. Further study comparing neoadjuvant CRT to standard treatment approaches for gastric cancer is indicated.
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Affiliation(s)
- Joseph M Pepek
- Department of Radiation Oncology, Duke University School of Medicine, Box 3085, Durham, NC, 27710, USA
| | - Junzo P Chino
- Department of Radiation Oncology, Duke University School of Medicine, Box 3085, Durham, NC, 27710, USA
| | - Christopher G Willett
- Department of Radiation Oncology, Duke University School of Medicine, Box 3085, Durham, NC, 27710, USA
| | - Manisha Palta
- Department of Radiation Oncology, Duke University School of Medicine, Box 3085, Durham, NC, 27710, USA
| | - Dan G Blazer III
- Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Douglas S Tyler
- Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Hope E Uronis
- Department of Medicine, Division of Medical Oncology, Duke University School of Medicine, Durham, NC, USA
| | - Brian G Czito
- Department of Radiation Oncology, Duke University School of Medicine, Box 3085, Durham, NC, 27710, USA
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Inoue T, Yachida S, Usuki H, Kimura T, Hagiike M, Okano K, Suzuki Y. Pilot feasibility study of neoadjuvant chemoradiotherapy with S-1 in patients with locally advanced gastric cancer featuring adjacent tissue invasion or JGCA bulky N2 lymph node metastases. Ann Surg Oncol 2012; 19:2937-45. [PMID: 22466666 DOI: 10.1245/s10434-012-2332-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND To improve the prognosis of locally advanced gastric cancer, clinical trials of neoadjuvant chemotherapy (NAC) are being performed. Although neoadjuvant chemoradiotherapy (NACRT) generally achieves superior local tumor control to NAC, its efficacy for locally advanced gastric cancers remains unclear. Therefore, a prospective trial was conducted to explore the feasibility and safety of NACRT with oral S-1 in a series of cases. METHODS Patients who had Japanese Gastric Cancer Association (JGCA) cStage IIIB gastric cancer were enrolled onto this study and received oral S-1 (65 mg/m(2)/day) administration and 50-Gy radiotherapy followed by radical surgery. The primary end points were completion of therapy and safety. RESULTS Between October 2005 and September 2008, 12 eligible patients were enrolled. Two could not complete the chemotherapy because of grade 3 toxicity. R0 resections were performed in 11 patients (91.7 %) (95 % confidence interval 61.5-99.8). Although operative morbidity was observed in two cases, there were no postoperative deaths. A pathologic response was observed in 10 patients (83.3 %). In five (62.5 %) of eight gastric cancers with invasion to adjacent structures, microscopic tumor deposits were not found in the affected organs. The 3-year survival rate was 58.3 % during a median follow-up period of 36 months. CONCLUSIONS Although this study is preliminary, the present regimen seems to be feasible and safe as a treatment for locally advanced gastric cancers featuring adjacent tissue invasion or JGCA bulky N2 disease. This treatment approach should now be tested using the new tumor, node, metastasis staging system in a large clinical trial.
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Affiliation(s)
- Tatsushi Inoue
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Kagawa, Japan.
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Abstract
The incidence of gastric cancer in India is low compared to developed countries, though there are certain geographical areas (Southern part and northeastern states of country) where the incidence is comparable to high-incidence areas of world. Despite the large number of patients being treated for gastric cancer, there are not sufficient publications discussing associated risk factors and outcomes in these patients. This article discusses relevant Indian epidemiological and clinical studies about gastric cancers. This article also highlights the gap in publication from India and developed countries regarding gastric cancer and stresses on collaborative efforts of the Indian scientific community to conduct epidemiological, pathological, and clinical studies to have a new standard of care for Indian patients.
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Affiliation(s)
- Atul Sharma
- Department of Medical Oncology, Dr. B. R. A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
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Ng DCK, Wong SKH, Ng WT, Lee AWM, Li MKW. Impact of adjuvant chemoradiation for adenocarcinoma of stomach after curative gastrectomy in Chinese: A 7-year audit. SURGICAL PRACTICE 2010. [DOI: 10.1111/j.1744-1633.2010.00504.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Mezhir JJ, Tang LH, Coit DG. Neoadjuvant therapy of locally advanced gastric cancer. J Surg Oncol 2010; 101:305-14. [PMID: 20187070 DOI: 10.1002/jso.21483] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Treatment of gastric cancer has evolved with the advent of randomized trials demonstrating chemotherapeutic agents with efficacy in advanced disease. Level I evidence supports delivering chemotherapy in the neoadjuvant setting; the data shows improvement in progression-free and overall survival. A clinical response to therapy is associated with improved R0 resection rates, pathologic response, and outcome in patients with locally advanced disease. Early assessment of metabolic response to therapy can potentially be utilized to tailor treatment.
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Affiliation(s)
- James J Mezhir
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA.
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DVORAK J, MELICHAR B, PETERA J, KABELAC K, VOSMIK M, VESELY P, SIRAK I, ZOUL Z, RYSKA A, JANDIK P. Preoperative neoadjuvant chemoradiation for locally advanced gastric adenocarcinoma. Rep Pract Oncol Radiother 2009; 14:169-175. [DOI: 10.1016/s1507-1367(10)60032-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Rivera F, Galán M, Tabernero J, Cervantes A, Vega-Villegas ME, Gallego J, Laquente B, Rodríguez E, Carrato A, Escudero P, Massutí B, Alonso-Orduña V, Cardenal A, Sáenz A, Giralt J, Yuste AL, Antón A, Aranda E. Phase II trial of preoperative irinotecan-cisplatin followed by concurrent irinotecan-cisplatin and radiotherapy for resectable locally advanced gastric and esophagogastric junction adenocarcinoma. Int J Radiat Oncol Biol Phys 2009; 75:1430-6. [PMID: 19540072 DOI: 10.1016/j.ijrobp.2008.12.087] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Revised: 12/22/2008] [Accepted: 12/29/2008] [Indexed: 01/27/2023]
Abstract
PURPOSE To determine in a Phase II trial whether preoperative irinotecan-cisplatin (IC) followed by concurrent IC therapy and radiotherapy (IC/RT) improved outcome in patients with resectable, locally advanced gastric adenocarcinoma (GC) or esophagogastric junction cancer (EGJC). PATIENTS AND METHODS Patients with resectable Stage II-IV, M0 GC or EGJC made up the study population. The primary endpoint was pathologic complete response (pCR). Two courses of IC (irinotecan, 65 mg/m(2); cisplatin, 30 mg/m(2) on Days 1 and 8 every 21 days) were given. Patients without progression then received IC/RT, consisting of daily radiotherapy (45Gy) with concurrent IC (irinotecan, 65 mg/m(2); cisplatin, 30 mg/m(2) on Days 1, 8, 15, and 22). Surgical resection was performed, if feasible, 5-8 weeks after the end of radiotherapy. RESULTS Twenty-three patients were included in the study: 10 with EGJC and 13 with GC. Two patients (9%) achieved pCR. The incidences of Grade 3-4 toxicities were as follows: IC: neutropenia 35% (febrile 13%), anemia 22%, diarrhea 22%, emesis 8%; IC/RT: neutropenia 52% (febrile 5%), asthenia 19%, anemia 9%, emesis 9%, diarrhea 5%, cardiotoxicity 5%. No patients died during IC or IC/RT. R0 resection was achieved in 15 patients (65%). Median survival was 14.5 months, and the actuarial 2-year survival rate was 35%. CONCLUSIONS Preoperative IC followed by IC/RT resulted in moderate response and resection rates with mild toxicity in patients with GC and EGJC.
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Affiliation(s)
- Fernando Rivera
- Department of Medical Oncology, Hospital Universitario Marqués de Valdecilla, Santander, Spain.
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Matzinger O, Gerber E, Bernstein Z, Maingon P, Haustermans K, Bosset JF, Gulyban A, Poortmans P, Collette L, Kuten A. EORTC-ROG expert opinion: radiotherapy volume and treatment guidelines for neoadjuvant radiation of adenocarcinomas of the gastroesophageal junction and the stomach. Radiother Oncol 2009; 92:164-75. [PMID: 19375186 DOI: 10.1016/j.radonc.2009.03.018] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2009] [Accepted: 03/05/2009] [Indexed: 01/20/2023]
Abstract
PURPOSE The Gastro-Intestinal Working Party of the EORTC Radiation Oncology Group (GIWP-ROG) developed guidelines for target volume definition in neoadjuvant radiation of adenocarcinomas of the gastroesophageal junction (GEJ) and the stomach. METHODS AND MATERIALS Guidelines about the definition of the clinical target volume (CTV) are based on a systematic literature review of the location and frequency of local recurrences and lymph node involvement in adenocarcinomas of the GEJ and the stomach. Therefore, MEDLINE was searched up to August 2008. Guidelines concerning prescription, planning and treatment delivery are based on a consensus between the members of the GIWP-ROG. RESULTS In order to support a curative resection of GEJ and gastric cancer, an individualized preoperative treatment volume based on tumour location has to include the primary tumour and the draining regional lymph nodes area. Therefore we recommend to use the 2nd English Edition of the Japanese Classification of Gastric Carcinoma of the Japanese Gastric Cancer Association which developed the concept of assigning tumours of the GEJ and the stomach to anatomically defined sub-sites corresponding respectively to a distinct lymphatic spread pattern. CONCLUSION The GIWP-ROG defined guidelines for preoperative irradiation of adenocarcinomas of the GEJ and the stomach to reduce variability in the framework of future clinical trials.
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Mansour JC, Schwarz RE. Pathologic Response to Preoperative Therapy: Does It Mean What We Think It Means? Ann Surg Oncol 2009; 16:1465-79. [DOI: 10.1245/s10434-009-0374-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2008] [Revised: 01/06/2009] [Accepted: 01/15/2009] [Indexed: 12/31/2022]
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Abstract
Complete surgical resection remains the primary curative treatment option for patients with early stage gastric adenocarcinoma appropriately staged with an adequate lymphadenectomy. Unfortunately, only 40% patients who undergo curative resection at the authors' institution will have early stage (i.e., stage IA or T2N0M0) disease; thus, the majority of patients will remain at high risk for recurrence after complete resection. At present, the authors advocate rigorous preoperative staging studies to identify patients with high-risk gastric cancer who are unlikely to benefit from single modality therapy, namely surgery alone, and assign them to undergo neoadjuvant chemotherapy before an attempt at curative resection. Patients who are determined to have high-risk disease postoperatively should be offered adjuvant therapy that will address the site of recurrence most likely to affect survival.
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Affiliation(s)
- Michael G House
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
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Jiang Y, Kimchi ET, Montero AJ, Staveley-O'Carroll KF, Ajani JA. Upper gastrointestinal tumors: current status and future perspectives. Expert Rev Anticancer Ther 2008; 8:975-91. [PMID: 18533807 DOI: 10.1586/14737140.8.6.975] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Recent therapeutic developments that have provided new promising and successful approaches to the treatment of solid tumors are in large part due to the increasing understanding of their molecular biology. Despite this progress, these new therapies have provided minimal benefit in the treatment of upper gastrointestinal (GI) malignancies. Hence, the overall survival of patients with upper GI tumors remains dismal. These disappointing results are largely due to the lack of early detection strategies, inadequate medical treatments and the poor understanding of upper GI tumor biology. Clinically, the treatment paradigm has been evolving for these malignancies. Esophageal cancer is now commonly treated with preoperative chemoradiation in the USA, in both academic and community cancer centers, due to its theoretical advantages. Adjuvant chemotherapy and chemoradiation are also frequently used in patients with pancreatic cancer. Exciting prospects remain in the medical and surgical treatment of these malignancies with the inclusion of biologic agents in many protocols, newer chemotherapeutic agents (such as S-1 in the treatment of gastric cancer), and the use of minimally invasive procedures for the treatment of premalignant and, possibly, early malignant lesions of the esophagus and stomach. This review focuses on the current practice in the management of upper GI tumors and summarizes the recent advances in the field.
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Affiliation(s)
- Yixing Jiang
- Penn State Hershey Cancer Institute, Penn State College of Medicine, 500 University Drive, Penn State Cancer Institute, Hershey, PA 17033, USA.
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Ott K, Lordick F, Herrmann K, Krause BJ, Schuhmacher C, Siewert JR. The new credo: induction chemotherapy in locally advanced gastric cancer: consequences for surgical strategies. Gastric Cancer 2008; 11:1-9. [PMID: 18373171 DOI: 10.1007/s10120-007-0448-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2007] [Accepted: 12/03/2007] [Indexed: 02/07/2023]
Abstract
Perioperative chemotherapy in stage II and stage III gastric cancer is now accepted as a standard of care in the Western world. Two randomized phase III studies have shown improved survival for patients with induction chemotherapy followed by surgery compared with surgery alone. It is generally accepted that patients who respond to induction therapy have a significantly improved survival compared with that in nonresponding patients. Unfortunately no prospectively tested markers predicting response and/or prognosis are available for clinical practice. In adenocarcinomas of the esophagogastric junction (AEG), fluorodeoxyglucose-positron emission tomography (FDG-PET) prospectively was established as a surrogate predicting response and prognosis. The MUNICON (Metabolic response evalUatioN for Individualisation of neoadjuvant Chemotherapy in oesOphageal and oesophagogastric adeNocarcinoma) I study confirmed prospectively the usefulness of early metabolic response evaluation and showed the feasibility of a PET-guided treatment algorithm. These findings are an important step forward in the tailoring of multimodal treatment in accordance with tumor biology. In gastric cancer, we have analyzed FDG-PET in a prospective study. In gastric cancer the issue is more complicated, because about 30% of gastric cancers cannot be visualized with sufficient contrast for quantification. Insufficient FDG uptake is mostly associated with diffuse-type gastric cancer with signet ring cells and mucinous content. In FDG-avid patients, FDG-PET can be used for response evaluation, comparable to that in AEG. The prognosis of FDG-nonavid patients is similar to that in metabolic nonresponders. The addition of new tracers such as fluorothymidine may increase the sensitivity of PET in the future. Treatment concepts such as immediate resection after only 2 weeks of induction therapy with or without adjuvant treatment could be considered in metabolic nonresponders, or modified chemotherapy regimens, possibly including biologically targeted drugs, could be considered in those with FDG-nonavid tumors.
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Affiliation(s)
- Katja Ott
- Department of Surgery, University of Heidelberg, Im Neuenheimer Feld 110, Heidelberg, Germany
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Kim MM, Mansfield PF, Das P, Janjan NA, Badgwell BD, Phan AT, Delclos ME, Maru D, Ajani JA, Crane CH, Krishnan S. Chemoradiation therapy for potentially resectable gastric cancer: clinical outcomes among patients who do not undergo planned surgery. Int J Radiat Oncol Biol Phys 2008; 71:167-72. [PMID: 18406886 DOI: 10.1016/j.ijrobp.2007.09.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Revised: 09/21/2007] [Accepted: 09/21/2007] [Indexed: 12/24/2022]
Abstract
PURPOSE We retrospectively analyzed treatment outcomes among resectable gastric cancer patients treated preoperatively with chemoradiation therapy (CRT) but rendered ineligible for planned surgery because of clinical deterioration or development of overt metastatic disease. METHODS AND MATERIALS Between 1996 and 2004, 39 patients with potentially resectable gastric cancer received preoperative CRT but failed to undergo surgery. At baseline clinical staging, 33 (85%) patients had T3-T4 disease, and 27 (69%) patients had nodal involvement. Most patients received 45 Gy of radiotherapy with concurrent 5-fluorouracil-based chemotherapy. Twenty-one patients underwent induction chemotherapy before CRT. Actuarial times to local control (LC), distant control (DC), and overall survival (OS) were calculated by the Kaplan-Meier method. RESULTS The cause for surgical ineligibility was development of metastatic disease (28 patients, 72%; predominantly peritoneal, 18 patients), poor performance status (5 patients, 13%), patient/physician preference (4 patients, 10%), and treatment-related death (2 patients, 5%). With a median follow-up of 8 months (range, 1-95 months), actuarial 1-year LC, DC, and OS were 46%, 12%, and 36%, respectively. Median LC and OS were 11.0 and 10.1 months, respectively. CONCLUSIONS Patients with potentially resectable gastric cancer treated with preoperative CRT are found to be ineligible for surgery principally because of peritoneal progression. Patients who are unable to undergo planned surgery have outcomes comparable to that of patients with advanced gastric cancer treated with chemotherapy alone. CRT provides durable LC for the majority of the remaining life of these patients.
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Affiliation(s)
- Michelle M Kim
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA
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An appraisal of radiation therapy techniques for adjuvant and neoadjuvant therapy in gastric cancer. JOURNAL OF RADIOTHERAPY IN PRACTICE 2008. [DOI: 10.1017/s1460396908006298] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACTIn last few years, adjuvant post-operative radiotherapy and occasionally preoperative irradiation combined with chemotherapy are considered as effective practices to improve disease control and survival in gastric cancer. Yet, chemoradiotherapy result in severe toxicities and radiotherapy practice is a significant contributor. For a recommended median dose of 45 Gy to the treatment volume of stomach and surrounding lymphnode regions, considerable doses are likely to be delivered to liver, kidneys and spinal cord. Few literatures and texts state about the radiotherapy techniques, with recent emphasis on conformal (3-D CRT) or intensity-modulated radiotherapy (IMRT). However, these facilities are not uniformly available in most developing countries where stomach cancer is common. This is a report on practical aspects of radiotherapy techniques and planning which can be utilised as per available settings of a radiotherapy department.
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