[The value of adjuvant and neoadjuvant chemotherapy in treatment of stomach carcinoma].
ABSTRACT The incidence of gastric adenocarcinoma has decreased dramatically in most Western countries over the past five decades. However, the five-year survival rate remains poor and late diagnosis is one of the main reasons for the lack of marked improvement in outcome. More than 50% of the patients found to have advanced local (stage T III), or systemic (stage T IV) gastric cancer at the time of diagnosis. This review article examines the current state of chemotherapeutic regimens additive to surgery, based on a computer-supported literature search (MED-LINE and CANCERLIT). Since 1980 15 randomized studies have been performed to evaluate the efficacy of systemic adjuvant chemotherapy. Of these, 13 were published in the Western English literature and 2 were Japanese studies, encompassing a total of over 2000 patients. In 3 studies adjuvant chemotherapy was administered intraperitoneally. An evaluation of these studies failed to demonstrate any advantage for the outcome of chemotherapy on patients with curative resected gastric carcinoma. Thus, according to present knowledge, this form of adjuvant treatment cannot be recommended for routine clinical management. In order to evaluate the effect of neoadjuvant chemotherapy, 17 randomized studies have been reviewed. In 6 studies (3 Western studies, 3 Japanese studies) neoadjuvant chemotherapy was investigated in patients with potentially curative resectable gastric carcinoma. 11 Western studies reported the results of neoadjuvant chemotherapy in cases of locally advanced disease. It appears that neoadjuvant chemotherapy of locally advanced non-resectable gastric cancer in patients who do not have distant metastases and/or "carcinosis peritonei" reduces tumor size in 30-40% of the patients, thus enabling radical resection in a second look operation. The efficacy of neoadjuvant chemotherapy in potentially resectable gastric carcinoma cannot be definitely assessed at the present time since only scant, preliminary findings are available. Future goals for the treatment of gastric carcinoma should include studies evaluating preoperative chemotherapy using effective, but less toxic substances, based on exact tumor-staging by means of endoluminal sonography. Furthermore, research projects investigating the value of intraperitoneal therapeutic regimens such as hyperthermic chemoperfusion or intraperitoneal instillation of the requisite substances in the prevention of intraperitoneal carcinomatosis and local recurrence will be of great importance.
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ABSTRACT: The aim of our study was to evaluate the accuracy of preoperative TNM staging with endoscopic ultrasound (EUS) in gastric cancer patients in comparison with the pathohistological stage of the resected specimen, and to determine the possible implications of EUS for individualized treatment of gastric cancer patients at our institution. The study included 82 patients operated for resectable gastric cancer between January 1(st) 2001 and July 1(st) 2003 at the Maribor Teaching Hospital Department of Abdominal and General Surgery. The EUS stage was assessed preoperatively at the Endoscopical Unit, and the pathohistological stage in the resected specimen was determined postoperatively at the Department of Pathologic Morphology according to recommended standards. Comparison of EUS and pathohistological assessments revealed accuracy of EUS staging for locoregional tumor infiltration (category T) in 68% of patients. The accuracy of EUS staging was 68% for T1, 69% for T2, 69% for T3 and 60% for T4. Lymph nodes (category N) were correctly staged with EUS in 57% of cases. The EUS stage was correct for lymph nodes with no metastases (N-) in 40% of cases, and for lymph nodes with metastases (N+) in 90%. There was no significant difference in accuracy of EUS staging with regard to tumor site (P = 0.768) or tumor size (P = 0.766). According to our results the accuracy of EUS staging matched pathohistological staging with regard to tumor infiltration and lymph node stage in 68% and 57% of cases respectively. Underestimation of the final T2 and T3 stages as T1 stage by EUS presents a problem regarding the consistency of EUS examination at our institution, particularly with respect to individual treatment for early gastric cancer. The present uncertainty in EUS stage reliability makes it necessary to have a strategy of radical resection with D2 lymphadenectomy in patients within EUS stages T1-T3, with additional CT examinations in more advanced EUS stages in order to visualize the circumstances of tumor growth. Nevertheless, EUS provides an opportunity for the surgeon to gain more insight into the loco-regional circumstances of the gastric tumor process. For development of individual modes of treatment based on EUS staging, a more reliable assessment of EUS stage is mandatory.Wiener klinische Wochenschrift 02/2006; 118 Suppl 2:48-51. DOI:10.1007/s00508-006-0552-y · 0.79 Impact Factor
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ABSTRACT: Peritoneal spread is a major cause of treatment failure and mortality in gastric cancer, even before this malignancy spreads to extraabdominal sites. Conventional adjuvant treatment options have failed in solving this problem to date. As shown in randomized controlled clinical trials, perioperative intraperitoneal chemotherapy can change the natural history of gastric cancer resected for cure, preventing the development of peritoneal carcinomatosis and improving long-term survival. A surgical approach that maximizes clearance and containment of the malignancy is required for this success. Additional reports have shown the value of intraperitoneal chemotherapy associated with cytoreductive surgery in the treatment of selected cases with established peritoneal spread. Surgeons treating gastric cancer patients need to realize that perioperative intraperitoneal chemotherapy becomes an integral part of the surgical treatment of this disease, for which they should accept responsibility. La diseminación peritoneal es una de las causas principales de fallo terapéutico y mortalidad en el cáncer gástrico, incluso antes de que éste se extienda fuera del abdomen. Ninguna de las opciones convencionales de tratamiento adyuvante ha conseguido solucionar este problema hasta el momento. Según se ha demostrado en ensayos clínicos aleatorios controlados, la quimioterapia intraperitoneal perioperatoria puede modificar la historia natural del cáncer gástrico resecado con intención curativa, evitando el desarrollo de carcinomatosis peritoneal y mejorando la supervivencia a largo plazo. Para ello se requiere un abordaje quirúrgico que maximice la contención y la erradicación del tejido tumoral. En otros trabajos se ha demostrado el valor de la quimioterapia intraperitoneal asociada con cirugía citorreductora en el tratamiento de casos seleccionados de carcinomatosis peritoneal establecida por cáncer gástrico. Los cirujanos que tratan a pacientes con cáncer gástrico deben comprender que la quimioterapia intraperitoneal perioperatoria se convierte en una parte integral del tratamiento quirúrgico de esta enfermedad de la que deberían hacerse responsables.Clinical and Translational Oncology 04/2012; 2(3):129-140. DOI:10.1007/BF02979480 · 2.08 Impact Factor