Published online Oct 15, 2014. doi: 10.4251/wjgo.v6.i10.393
Revised: July 1, 2014
Accepted: September 6, 2014
Published online: October 15, 2014
Adenocarcinoma of the stomach carries a poor prognosis and is the second most common cause of cancer death worldwide. It is recommended that surgical resection with a D1 or a modified D2 gastrectomy (with at least 15 lymph nodes removed for examination) be performed in the United States, though D2 lymphadenectomies should be performed at experienced centers. A D2 lymphadenectomy is the recommended procedure in Asia. Although surgical resection is considered the definitive treatment, rates of recurrences are high, necessitating the need for neoadjuvant or adjuvant therapy. This review article aims to outline and summarize some of the pivotal trials that have defined optimal treatment options for non-metastatic non-cardia gastric cancer. Some of the most notable trials include the INT-0116 trial, which established a benefit in concurrent chemoradiation and adjuvant chemotherapy. This was again confirmed in the ARTIST trial, especially in patients with nodal involvement. Later, the Medical Research Council Adjuvant Gastric Infusional Chemotherapy trial provided evidence for the use of perioperative chemotherapy. Targeted agents such as ramucirumab and trastuzumab are also being investigated for use in locally advanced gastric cancers after demonstrating a benefit in the metastatic setting. Given the poor response rate of this difficult disease to various treatment modalities, numerous studies are currently ongoing in an attempt to define a more effective therapy, some of which are briefly introduced in this review as well.
Core tip: Gastric adenocarcinoma is a difficult disease to treat. Surgical resection is the definitive therapy but recurrences are frequent. The use of a multidisciplinary approach to treatment decision-making is imperative. Surgical resection should be an R0 resection (with clear macroscopic and microscopic margins) and at least a D1 lymphadenectomy with a minimum of 15 lymph nodes sampled in the United States and a D2 lymphadenectomy elsewhere. Perioperative chemotherapy is a reasonable option based on the Medical Research Council Adjuvant Gastric Infusional Chemotherapy trial. In patients who are evaluated after resection, adjuvant chemoradiation adds important survival benefit. Other options include adjuvant S-1 in Asian patients, capecitabine/oxaliplatin, and capecitabine/cisplatin.