Retrospective Study
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Mar 7, 2015; 21(9): 2711-2718
Published online Mar 7, 2015. doi: 10.3748/wjg.v21.i9.2711
Neoadjuvant chemoradiotherapy followed by D2 gastrectomy in locally advanced gastric cancer
Mi Sun Kim, Joon Seok Lim, Woo Jin Hyung, Yong Chan Lee, Sun Young Rha, Ki Chang Keum, Woong Sub Koom
Mi Sun Kim, Ki Chang Keum, Woong Sub Koom, Department of Radiation Oncology, Yonsei University College of Medicine, Seoul 120-752, South Korea
Joon Seok Lim, Department of Radiology, Yonsei University College of Medicine, Seoul 120-752, South Korea
Woo Jin Hyung, Department of Surgery, Yonsei University College of Medicine, Seoul 120-752, South Korea
Yong Chan Lee, Department of Internal Medicine, Yonsei University College of Medicine, Seoul 120-752, South Korea
Sun Young Rha, Department of Medical Oncology, Yonsei University College of Medicine, Seoul 120-752, South Korea
Author contributions: Koom WS designed the study; Kim MS contributed to the study design, performed the statistical analysis, and wrote the manuscript; Lim JS, Hyung WJ, Lee YC, Rha SY and Keum KC performed the research and assisted in drafting the manuscript; all authors read and approved the final manuscript.
Ethics approval: The study was reviewed and approved by the Yonsei University Health System, Severance Hospital Institutional Review Board.
Informed consent: The study demonstrated minimal risk for included patients and received a waiver of informed consent from the Institutional Review Board.
Conflict-of-interest: All authors certify that no actual or potential conflict-of-interest in relation to this article exists.
Data sharing: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Woong Sub Koom, MD, Department of Radiation Oncology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, South Korea. mdgold@yuhs.ac
Telephone: +82-2-22288116 Fax: +82-2-3129033
Received: September 11, 2014
Peer-review started: September 12, 2014
First decision: October 29, 2014
Revised: November 19, 2014
Accepted: December 13, 2014
Article in press: December 16, 2014
Published online: March 7, 2015
Abstract

AIM: To investigate the efficacy of neoadjuvant chemoradiotherapy (NACRT) for resectability of locally advanced gastric cancer (LAGC).

METHODS: Between November 2007 and January 2014, 29 patients with LAGC (clinically T3 with distal esophagus invasion/T4 or bulky regional node metastasis) that were treated with NACRT followed by D2 gastrectomy were included in this study. Resectability was evaluated with radiologic and endoscopic exams before and after NACRT. Using three-dimensional conformal radiotherapy, patients received 45 Gy, with a daily dose of 1.8 Gy. The entire tumor extent and the regional metastatic lymph nodes were included in the gross tumor volume. Patients presenting with a resectable tumor after NACRT received a total or subtotal gastrectomy with D2 dissection. The pathologic tumor response was evaluated using Japanese Gastric Cancer Association histologic evaluation criteria. Postoperative morbidity was evaluated using the National Cancer Institute-Common Terminology Criteria for Adverse Events version 4.0. Overall survival (OS) and progression-free survival (PFS) rates were estimated using a Kaplan-Meier analysis and compared using the log-rank test.

RESULTS: All patients were assessed as unresectable cases. Twenty-four patients (24/29; 82.8%) showed LAGC on positron emission tomography-computed tomography (CT) and contrast-enhanced CT, whereas four patients (4/29; 13.8%) with vague invasion or abutment to an adjacent organ underwent diagnostic laparoscopy. One patient (1/29; 3.4%), initially assessed as a resectable case, underwent an “open and closure” after the tumor was found to be unresectable. Abutment to an adjacent organ (34.5%) was the most common reason for NACRT. The clinical response rate one month after NACRT was 44.8%. After NACRT, 69% (20/29) of patients had a resectable tumor. Of the 20 patients with a resectable tumor, 18 patients (62.1%) underwent a D2 gastrectomy. The R0 resection rate was 94.4% and two patients (2/18; 11.1%) showed a complete response. The median follow-up duration was 13.5 mo. The one-year OS and PFS rates were 72.4 and 48.9%, respectively. The one-year OS, PFS, local failure-free survival, and distant metastasis-free survival were higher in patients with a resectable tumor after NACRT (P < 0.001, P < 0.001, P < 0.001, and P = 0.078, respectively). No grade 3-4 late treatment-related toxicities or postoperative mortalities were observed.

CONCLUSION: NACRT with D2 gastrectomy showed a high rate of R0 resection and promising local control, which may increase the R0 resection opportunity resulting in survival benefit.

Keywords: Advanced gastric cancer, D2 gastrectomy, Neoadjuvant chemoradiotherapy, Combined modality therapy, Treatment outcome

Core tip: In locally advanced gastric cancer (LAGC), R0 resection is a well-established predictive factor. To achieve R0 resection, neoadjuvant approaches have been attempted. Studies of neoadjuvant chemotherapy followed by radical gastrectomy and D2 dissection have resulted in favorable outcomes and large studies of neoadjuvant chemotherapy are underway. Data on neoadjuvant chemoradiotherapy (NACRT) in LAGC are limited. This retrospective study was performed to investigate the efficacy of NACRT in LAGC. We found that NACRT increased the chance for an R0 resection and potentially enhanced survival in LAGC.