WITHDRAWN: Neoadjuvant chemotherapy versus none for resectable gastric cancer

Perioperative chemo(radio)therapy versus primary surgery for resectable adenocarcinoma of the stomach, gastroesophageal junction, and lower esophagus

BACKGROUND

The outcome of patients with locally advanced gastroesophageal adenocarcinoma (adenocarcinoma of the esophagus, gastroesophageal (GE) junction, and stomach) is poor. There is conflicting evidence regarding the effects of perioperative chemotherapy on survival and other outcomes.

OBJECTIVES

To assess the effect of perioperative chemotherapy for gastroesophageal adenocarcinoma on survival and other clinically relevant outcomes in the overall population of participants in randomized controlled trials (RCTs) and in prespecified subgroups.

SEARCH METHODS

We performed computerized searches in the Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Review of Effectiveness (DARE), the Cochrane Database of Systematic Reviews (CDSR) from The Cochrane Library, MEDLINE (1966 to May 2011), EMBASE (1980 to May 2011), and LILACS (Literatura Latinoamericana y del Caribe en Ciencias de la Salud), combining the Cochrane highly sensitive search strategy with specific search terms. Moreover, we handsearched several online databases, conference proceedings, and reference lists of retrieved papers.

SELECTION CRITERIA

We included RCTs which randomized patients with gastroesophageal adenocarcinoma, in the absence of distant metastases, to receive either chemotherapy with or without radiotherapy followed by surgery, or surgery alone.

DATA COLLECTION AND ANALYSIS

Two independent review authors identified eligible trials. We solicited individual patient data (IPD) from all selected trials. We performed meta-analyses based on intention-to-treat populations using the two-stage method to combine IPD with aggregate data from RCTs for which IPD were unavailable. We combined data from all trials providing IPD in a Cox proportional hazards model to assess the effect of several covariables on overall survival.

MAIN RESULTS

We identified 14 RCTs with 2422 eligible patients. For eight RCTs with 1049 patients (43.3%), we were able to obtain IPD. Perioperative chemotherapy was associated with significantly longer overall survival (hazard ratio (HR) 0.81; 95% confidence interval (CI) 0.73 to 0.89). This corresponds to a relative survival increase of 19% or an absolute survival increase of 9% at five years. This survival advantage was consistent across most subgroups. There was a trend towards a more pronounced treatment effect for tumors of the GE junction compared to other sites, and for combined chemoradiotherapy as compared to chemotherapy in tumors of the esophagus and GE junction. Resection with negative margins was a strong predictor of survival. Multivariable analysis showed that tumor site, performance status, and age have an independent significant effect on survival. Moreover, there was a significant interaction of the effect of perioperative chemotherapy with age (larger treatment effect in younger patients). Perioperative chemotherapy also showed a significant effect on several secondary outcomes. It was associated with longer disease-free survival, higher rates of R0 resection, and more favorable tumor stage upon resection, while there was no association with perioperative morbidity and mortality.

AUTHORS' CONCLUSIONS

Perioperative chemotherapy for resectable gastroesophageal adenocarcinoma increases survival compared to surgery alone. It should thus be offered to all eligible patients. There is a trend to a larger survival advantage for tumors of the GE junction as compared to other sites and for chemoradiotherapy as compared to chemotherapy in esophageal and GE junction tumors. Likewise, there is an interaction between age and treatment effect, with younger patients having a larger survival advantage, and no survival advantage for elderly patients.

Gastric linitis plastica: which role for surgical resection?

BACKGROUND

The role of surgery for gastric linitis plastica (GLP) is questioned. This study aimed to analyze our experience in the surgical treatment of GLP with specific reference to the resectability rate, prognosis, and mode of recurrence.

METHODS

Results of surgery were analyzed in 102 patients with GLP.

RESULTS

Of the 102 patients, 92 underwent surgical exploration, with resection performed in 60 cases. R2 resection was carried out in 20 patients and R1 in 12 patients, while the resection was considered potentially curative (R0) in 28 (27.5%). Overall, the median (95% confidence interval [CI]) survival time was 5.7 (3.7-7.5) months, with none of the patients alive at the end date of the study. For R0 patients the median (95% CI) survival time was 15.8 (11-20.7) months. The great majority of recurrences were intra-abdominal (peritoneal and/or locoregional), with a systemic component of the relapse that was rarely observed (5 cases).

CONCLUSIONS

After primary surgery, GLP showed a poor prognosis without regard to the extent or type of resection. The failure of surgical treatment related mainly to the peritoneal spread of the disease. Specifically designed multimodality treatment protocols should be tested in this setting.

7-Year survival results of perioperative chemotherapy with epidoxorubicin, etoposide, and cisplatin (EEP) in locally advanced resectable gastric cancer: up-to-date analysis of a phase-II study

BACKGROUND

Perioperative chemotherapy is considered an effective treatment option for patients with gastric carcinoma. We report the results after a 7-year follow-up of a study aimed at evaluating a perioperative chemotherapy protocol in a group of patients with locally advanced gastric cancer (LAGC).

METHODS

Between February 1996 and May 2000, 24 patients with LAGC underwent D2-gastrectomy after three preoperative cycles of chemotherapy (Epidoxorubicin, Etoposide, Cisplatinum). Three further cycles were planned after surgery. Differences among groups were evaluated using the chi-square test. Survival rate was calculated after a 7-year follow-up, and differences were assessed using the log-rank test. Multivariate analysis was performed using the Cox proportional hazard model.

RESULTS

A total of 24 patients received preoperative chemotherapy and underwent surgical resection. Of these, 17 (71%) received postoperative treatment. The main toxicity was grade 3-4 neutropenia. Curative resection (R0) was achieved in 83.3% of patients. No pathologic complete responses were documented, but tumor downstaging was obtained in 10 of 24 patients (41.7%). Overall median survival was 40 months, and 7-year survival rate was 46%. At univariate and multivariate analysis, R0 resection and tumor diameter were the most important prognostic factors.

CONCLUSION

Long-term results in our series show a survival benefit for LAGC patients treated by perioperative chemotherapy and D2-gastrectomy when compared with previously studied controls who had surgery with postoperative chemotherapy alone. The high rate and prognostic impact of R0 resection in this study stressed the role of the therapy during the preoperative phase.