Perioperative Chemotherapy Compared With Surgery Alone for Resectable Gastroesophageal Adenocarcinoma: An FNCLCC and FFCD Multicenter Phase III Trial

Preoperative chemotherapy does not influence the number of evaluable lymph nodes in resected gastric cancer

BACKGROUND

While it is suggested that more than 15 lymph nodes (LNs) should be evaluated for accurate staging of gastric cancer, LN yield in western countries is generally low. The effect of preoperative chemotherapy on LN yield in gastric cancer is unknown. The aim of the present study is to determine whether preoperative chemotherapy is associated with any difference in the number of LNs obtained from specimens of patients who underwent curative surgery for gastric adenocarcinoma.

PATIENTS AND METHODS

In 1205 patients from Memorial Sloan-Kettering Cancer Center (MSKCC) and 1220 patients from the Netherlands Cancer Registry (NCR) who underwent a gastrectomy with curative intent for gastric adenocarcinoma without receiving preoperative radiotherapy, LN yield was analyzed, comparing patients who received preoperative chemotherapy and patients who received no preoperative therapy.

RESULTS

Of the 2425 patients who underwent a gastrectomy, 14% received preoperative chemotherapy. Median LN yields were 23 at MSKCC and 10 in the NCR. Despite this twofold difference in LN yield between the two populations, with multivariate Poisson regression, chemotherapy was not associated with LN yield of either population. Variables associated with increased LN yield were institution, female sex, lower age, total (versus distal) gastrectomy and increasing T-stage.

CONCLUSIONS

In this patient series, treatment at MSKCC, female sex, lower age, total gastrectomy and increasing primary tumor stage were associated with a higher number of evaluated LNs. Preoperative chemotherapy was not associated with a decrease in LN yield. Evaluating more than 15 LNs after gastrectomy is feasible, with or without preoperative chemotherapy.

Predicting the response to chemotherapy in gastric adenocarcinoma: who benefits from neoadjuvant chemotherapy?

Despite a decline in the overall incidence, gastric adenocarcinoma remains the second most common cause of cancer death worldwide and thus a significant global health problem. Even in early-stage locoregional confined disease the 5-year survival rarely exceeds 25-35 %. Randomized trials have demonstrated a benefit from neoadjuvant and perioperative chemotherapy. However the optimal approach in individual patients is not clear and remains controversial. A consistent finding is that patients who have a histopathological response to neoadjuvant therapy are more likely to receive a survival benefit. These clinical data provide a strong argument for the urgent development of methods to predict histopathological response to neoadjuvant therapies for gastric adenocarcinomas. Published data demonstrate that clinico-pathological features (tumour histology and location), imaging through metabolic response by FDG-PET and tissue/molecular biomarkers may all have a predictive value for neoadjuvant therapies. However it is still uncertain from published data whether or not they will be useful for clinical decision making in individual patients. Existing candidate biomarkers need to be properly qualified and validated and novel biomarkers are required and an optimal approach should involve the combination and integration of clinical, imaging, pathological and molecular biomarkers.

Radiotherapy of gastroesophageal junction cancer

Adenocarcinomas of the gastroesophageal junction (GEJ) require multimodal treatment approaches to accomplish good local control and overall survival. While early T1/2 N0 tumors are treated with surgery alone, they are only found in a small subset of patients due to the lack of symptoms at this stage. Most of the tumors are detected in locally advanced stage where surgery alone results in disappointing outcome. Chemotherapy and/or chemoirradiation in the neoadjuvant setting are used to improve conditions for oncological surgery. They aim to achieve a downsizing with a pathological complete remission in the optimal case, improve R0 rates, and upfront treat microscopic metastatic tumor cells. The optimal neoadjuvant treatment approach-chemotherapy, chemoirradiation, or a multiphase approach of both-is yet unclear. Chemoirradiation can improve local control after incomplete surgery and is an important option for patients unfit for surgery. In addition, it enables symptom relief in a palliative setting, namely dysphagia, pain, or bleeding. While target volumes are very much standardized, new technologies as image-guided intensity-modulated radiotherapy (IG-IMRT) and particle therapy have the potential to improve the therapeutic window by minimizing toxicity. Challenges of the present and the future will be the combination of radiotherapy with other cytostatic drugs and modern targeted therapies. This should ideally be integrated into a multimodal setting that is able to identify risk groups according to predictive markers and tumor response, altogether leading to a personalized oncological approach.

Will disease heterogeneity help define treatment paradigms for gastroesophageal adenocarcinoma? A global perspective

Cancers of the upper gastrointestinal (GI) tract form a heterogeneous group of diseases for which treatment paradigms for localized disease continue to emerge. Recently, several phase III studies in esophagus and gastric cancer that have attempted to define new standards of care have been reported. However, controversy still persists and treatment algorithms often depend on individual preference, patient referral patterns, and treatment biases. In the current era of improving quality control and standardization of care, such variations in practice present a substantial challenge for both patients and physicians. In this article, I will highlight differences in disease biology for upper GI diseases, and in particular, gastric cancer.

Adjuvant chemotherapy: an option for Asian patients only?

Survival rates following curative resection for gastric cancer are higher in East Asia than in Europe and the US. The aggressive surgical approach adopted in East Asia may explain these observations. In Japan and Korea, gastrectomy with extended lymphadenectomy (D2 gastrectomy) has been standard of care for many years, whereas gastrectomy with lymphadenectomy of the perigastric lymph nodes (D1 surgery) has been favored in Europe and the US until recently. D2 surgery is now recommended globally based on the 15-year findings from the large Dutch D1D2 study, which showed a reduction in cancer-related deaths with D2 versus D1 surgery. Improved outcomes are now being reported in the US and Europe as D2 surgery becomes more widely used. In addition to surgery, systemic therapy is also required to control recurrences, although the preferred regimen differs by region. Given that some of the studies on which these preferences are based predate the widespread acceptance of D2 surgery, the optimal regimen should be considered carefully. Recent studies from East Asia support the use of adjuvant chemotherapy after D2 surgery. Adjuvant chemotherapy should also be considered a valid approach in other regions now that the benefits of D2 surgery have been demonstrated unequivocally.

Chemotherapy for operable gastric cancer: current perspectives

The majority of gastric cancer patients present with advanced, incurable disease and only a minority have localised disease that is suitable for radical treatment. A benefit has generally been demonstrated from adding chemotherapy to surgery for early disease though there are marked differences in how this is done globally. Whilst a perioperative approach, with chemotherapy given before and after gastric surgery is commonly used in the Europe and Australia most patients with operable gastric cancer in North America are treated with surgery and postoperative chemoradiation. In contrast, in East Asia, adjuvant fluoropyrimidine chemotherapy alone is used following D2 gastric resection surgery. However, despite the multimodality treatments, outcomes remain suboptimal as the majority of those treated for localised disease eventually relapse with incurable loco-regional or distant metastases. At the current time, an unmet need exists to further understand the biology of this aggressive disease and develop more efficacious therapies that can improve outcomes from this aggressive disease.

A comparison of multimodality treatment: two and four courses of neoadjuvant chemotherapy using S-1/CDDP or S-1/CDDP/docetaxel followed by surgery and S-1 adjuvant chemotherapy for macroscopically resectable serosa-positive gastric cancer: a randomized phase II trial (COMPASS-D trial)

This randomized Phase II trial will compare the outcome of neoadjuvant chemotherapy using two and four courses of S-1 plus cisplatin or S-1 plus cisplatin plus docetaxel by a two-by-two factorial design for patients with macroscopically resectable serosa-positive gastric cancer. After neoadjuvant chemotherapy, patients will receive D2 gastrectomy followed by S-1 chemotherapy for 1 year postoperatively. The primary endpoint is the 3-year overall survival. The sample size is 120 for the two hypotheses: the superiority of four courses compared with two courses and the superiority of S-1 plus cisplatin plus docetaxel compared with S-1 plus cisplatin. This trial will be able to define the more suitable number of cycles and better regimen of neoadjuvant chemotherapy for gastric cancer.

Perioperative docetaxel, cisplatin, and 5-fluorouracil (DCF) for locally advanced esophageal and gastric adenocarcinoma: a multicenter phase II trial

BACKGROUND

Although perioperative chemotherapy for esophagogastric adenocarcinoma (ADC) improves survival, the overall poor prognosis suggests that further refinement of treatment is required. Docetaxel, cisplatin, and 5-fluorouracil (5-FU) (DCF) is effective for metastatic ADC of the upper gastrointestinal (GI) tract; we thus sought to investigate the efficacy of this regimen in patients with resectable disease.

PATIENTS AND METHODS

Patients with resectable ADC of the upper GI tract received DCF [docetaxel (Taxotere) 75 mg/m(2) I.V. day 1, cisplatin 75 mg/m(2) I.V. day 1, 5-FU 750 mg/m(2) continuous infusion for 120 h, every 3 weeks] for three cycles before and after resection. Primary end point was complete resection; secondary end points were response, toxicity, surgical morbidity, and overall survival.

RESULTS

Forty-three patients with ADC of the esophagus (11), gastroesophageal junction (25), or stomach (7) started treatment and 86% completed all preoperative cycles with grade 3-4 toxicity arising in 47%. Metabolic response to chemotherapy (reduction in maximal standard uptake value >35%) was achieved in 25/33 (76%) patients. Surgery was carried out in 41/43 and complete resection was achieved in all 41 patients with pathologic complete response in 4/41. Postoperative chemotherapy was started in 29 patients and completed in 24. Three-year overall survival was 60%.

CONCLUSION

Perioperative DCF is a tolerable and highly effective regimen for the treatment of esophagogastric ADC.

Treatment strategies in gastric cancer

BACKGROUND

Gastric cancer has become less common but remains among the leading causes of death from cancer, with a 5-year survival rate of only 20% to 25%. Although diagnostic techniques have improved, most patients with gastric cancer in the Western world (unlike in some Asian countries) already have locally advanced disease when diagnosed and may thus need not only surgery, but also perioperative chemotherapy and/or radiotherapy.

METHOD

Articles published from 2000 to 2010 and containing the terms "gastric cancer," "surgery," and "chemotherapy" in combination with "review" or "randomized trial" were retrieved by a search in the Cochrane Library and Medline databases and selectively reviewed.

RESULTS

Complete (R0) resection of the tumor remains the standard treatment whenever possible. Complete endoscopic resection suffices only in special types of carcinoma that are confined to the gastric mucosa. Depending on the histological findings, either a subtotal distal gastrectomy or a total (perhaps extended total) gastrectomy can be performed. The long-term benefit of systematic D2 lymphadenectomy has now been shown in a randomized trial: the rates of tumor-related death and of local or regional recurrence were found to be significantly lower with D2 than with D1 lymphadenectomy. Multimodal treatment strategies including perioperative chemotherapy and/or radiotherapy can further improve local and regional tumor control and lessen the rate of systemic metastasis.

CONCLUSION

The standardization of surgical procedures lowered the operative risk in the treatment of gastric cancer. Patients with locally advanced disease can now derive additional benefit from perioperative chemotherapy with an increase of the 5-year survival rates of more than 10%.

Is there any advantage to combined trastuzumab and chemotherapy in perioperative setting her 2neu positive localized gastric adenocarcinoma?

We report here a 44-year-old Moroccan man with resectable gastric adenocarcinoma with overexpression of human epidermal growth factor receptor 2 (HER2) by immunohistochemistry who was treated with trastuzumab in combination with chemotherapy in perioperative setting. He received 3 cycles of neoadjuvant chemotherapy consisting of trastuzumab, oxaliplatin, and capecitabine. Afterwards, he received total gastrectomy with extended D2 lymphadenectomy without spleno-pancreatectomy. A pathologic complete response was obtained with a combination of trastuzumab and oxaliplatin and capecitabine. He received 3 more cycles of trastuzumab containing regimen postoperatively.

We conclude that resectable gastric carcinoma with overexpression of the c-erbB-2 protein should ideally be managed with perioperative combination of trastuzumab with chemotherapy. Further research to evaluate trastuzumab in combination with chemotherapy regimens in the perioperative and adjuvant setting is urgently needed.

Use of multimodality neoadjuvant therapy for esophageal cancer in the United States: assessment of 987 hospitals

BACKGROUND

Consensus guidelines recommend neoadjuvant therapy in locally advanced esophageal cancer; however, whether this recommendation has been widely adopted is unknown. Therefore, we evaluated the utilization of neoadjuvant therapy in esophageal cancer and its association with outcomes in the United States.

METHODS

From the National Cancer Data Base all patients with middle and lower third clinical stage I-III esophageal cancers who underwent surgical resection were identified (1998-2007). Multivariable regression models were developed to identify predictors of neoadjuvant therapy use and associated outcomes.

RESULTS

We identified 8562 patients who underwent surgical resection for esophageal cancer. In nonmetastatic locally advanced tumors, neoadjuvant therapy use increased (stage II 47.9% to 72.5%; stage III 51.0% to 90.1%; P < 0.001). On multivariable analysis, factors associated with the decreased use of neoadjuvant therapy for stage II and III disease were age ≥75 years, Medicare insurance coverage, Charlson score ≥2, stage II (vs. III) disease, and geographic region. Patients with stage II and III disease who underwent neoadjuvant therapy had a lower risk of positive lymph nodes (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.35-0.55) and positive surgical margins (OR 0.51, 95% CI 0.38-0.69). Thirty-day postoperative mortality rates were not significantly affected by neoadjuvant therapy (OR 0.90, 95% CI 0.66-1.24). A pathologic complete response was observed in 10.8% of patients. The only factor that was predictive of pathologic complete response was squamous cell tumor histology (OR 2.14, 95% CI 1.52-3.02).

CONCLUSIONS

In surgically treated patients, the use of neoadjuvant trimodal therapy has increased in the past decade; however, opportunities exist to improve adherence to national guidelines.

Latest developments and emerging treatment options in the management of stomach cancer

Gastric cancer remains a significant health burden worldwide. Most of these malignancies are diagnosed at an advanced stage and are associated with a grim prognosis. Complete removal of macroscopic and microscopic tumor masses along with regional lymphnodes (R0 surgical resection) represents the treatment of choice in localized, nonmetastatic gastric cancer. Chemotherapy, either alone as a perioperative treatment, or in combination with radiation therapy in an adjuvant setting, improves the clinical outcome for patients with resectable tumors. In patients suffering from metastatic disease, chemotherapy and the so-called targeted therapies play a major role in improving survival and quality of life compared with best supportive care. The emergence of new drugs as well as new administration schedules allow physicians to obtain an objective response of up to 60% and, since the utilization of targeted therapies, overall survival has reached 14 months. In order to situate the standard of care and the latest developments in gastric malignancies better, the pertinent English literature, including major Phase III randomized studies and meta-analyses, has been reviewed.

Survival after neoadjuvant chemotherapy or chemoradiotherapy for resectable oesophageal carcinoma: an updated meta-analysis

BACKGROUND

In a previous meta-analysis, we identified a survival benefit from neoadjuvant chemotherapy or chemoradiotherapy before surgery in patients with resectable oesophageal carcinoma. We updated this meta-analysis with results from new or updated randomised trials presented in the past 3 years. We also compared the benefits of preoperative neoadjuvant chemotherapy compared with neoadjuvant chemoradiotherapy.

METHODS

To identify additional studies and published abstracts from major scientific meetings, we searched Medline, Embase, and Central (Cochrane clinical trials database) for studies published since January, 2006, and also manually searched for abstracts from major conferences from the same period. Only randomised studies analysed by intention to treat were included, and searches were restricted to those databases citing articles in English. We used published hazard ratios (HRs) if available or estimates from other survival data. We also investigated treatment effects by tumour histology and relations between risk (survival after surgery alone) and effect size.

FINDINGS

We included all 17 trials from the previous meta-analysis and seven further studies. 12 were randomised comparisons of neoadjuvant chemoradiotherapy versus surgery alone (n=1854), nine were randomised comparisons of neoadjuvant chemotherapy versus surgery alone (n=1981), and two compared neoadjuvant chemoradiotherapy with neoadjuvant chemotherapy (n=194) in patients with resectable oesophageal carcinoma; one factorial trial included two comparisons and was included in analyses of both neoadjuvant chemoradiotherapy (n=78) and neoadjuvant chemotherapy (n=81). The updated analysis contained 4188 patients whereas the previous publication included 2933 patients. This updated meta-analysis contains about 3500 events compared with about 2230 in the previous meta-analysis (estimated 57% increase). The HR for all-cause mortality for neoadjuvant chemoradiotherapy was 0.78 (95% CI 0.70-0.88; p<0.0001); the HR for squamous-cell carcinoma only was 0.80 (0.68-0.93; p=0.004) and for adenocarcinoma only was 0.75 (0.59-0.95; p=0.02). The HR for all-cause mortality for neoadjuvant chemotherapy was 0.87 (0.79-0.96; p=0.005); the HR for squamous-cell carcinoma only was 0.92 (0.81-1.04; p=0.18) and for adenocarcinoma only was 0.83 (0.71-0.95; p=0.01). The HR for the overall indirect comparison of all-cause mortality for neoadjuvant chemoradiotherapy versus neoadjuvant chemotherapy was 0.88 (0.76-1.01; p=0.07).

INTERPRETATION

This updated meta-analysis provides strong evidence for a survival benefit of neoadjuvant chemoradiotherapy or chemotherapy over surgery alone in patients with oesophageal carcinoma. A clear advantage of neoadjuvant chemoradiotherapy over neoadjuvant chemotherapy has not been established. These results should help inform decisions about patient management and design of future trials.

FUNDING

Cancer Australia and the NSW Cancer Institute.