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Past
No large, population-based studies comparing short-term outcomes and complications between neoadjuvant chemotherapy and upfront surgery in gastric adenocarcinoma exist. Clinical guidelines recommend perioperative chemotherapy for patients with stage ≥ IB resectable gastric cancer.1 Gastrectomy associates with frequent complications and high mortality.2 It is unknown whether surgical risks in neoadjuvant-treated patients are increased outside the selected clinical trial populations. To this date, there are only few small studies on this topic from Asia. They suggest either no significant difference in postoperative complications or less postoperative complications between neoadjuvant chemotherapy and upfront surgery.3,4 Because there are no nationwide studies, large Western studies, or studies using standardized definition of complications, it is important to determine the effect of neoadjuvant treatment on surgical risk in gastric cancer.
Present
The present study was designed to compare postoperative complication rates after gastric cancer resection in patients receiving neoadjuvant therapy compared with upfront surgery by using standardized definitions and in a population-based nationwide cohort in Finland.5 After adjustment for key confounders, neoadjuvant therapy was not associated with increased major postoperative complications, pneumonia, anastomotic complications, wound complications, or other complications, reoperations, or short-term mortality compared with upfront surgery.
Future
The current evidence suggests that neoadjuvant chemotherapy with platinum-based chemotherapy does not seem to increase the surgical risk of gastrectomy. Future studies should evaluate the effects of newer regimens, such as FLOT, on surgical complications, which may differ between regimens. One should not overlook evaluating immune-oncological treatments, such as nivolumab or pembrolizumab, because they are gaining popularity in the neoadjuvant setting of gastric cancer. Patient performance status may preclude neoadjuvant therapy in many instances. There may be some patient groups in whom neoadjuvant therapies are currently underutilized because of fear of complications. Although the dropout rate during neoadjuvant treatment was not available in this cohort, based on current evidence, the potentially increased surgical risk should not be used as grounds for withholding chemotherapy in otherwise eligible patients.
References
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Feng D, Leong M, Li T, Chen L, Li T. Surgical outcomes in patients with locally advanced gastric cancer treated with S-1 and oxaliplatin as neoadjuvant chemotherapy. World J Surg Oncol. 2015;13(1):1–9.
Li ZY, Shan F, Zhang LH, et al. Complications after radical gastrectomy following FOLFOX7 neoadjuvant chemotherapy for gastric cancer. World J Surg Oncol. 2011;9:110.
Putila E, Helminen O, Helmiö M, et al. Postoperative complications after neoadjuvant chemotherapy compared to upfront surgery in gastric adenocarcinoma, a population-based nationwide study in Finland. Ann Surg Oncol. 2023. https://doi.org/10.1245/s10434-023-14813-5.
Acknowledgment
FINEGO (The Finnish National Esophago-Gastric Cancer Cohort) collaborative group: Mika Helmiö (Division of Digestive Surgery and Urology, Turku University Hospital), Heikki Huhta (Surgery Research Unit, Medical Research Center Oulu. University Hospital and University of Oulu), Aapo Jalkanen (Department of Surgery, University of Helsinki and Helsinki University Hospital), Raija Kallio (Department of Oncology and Radiotherapy, Oulu University Hospital), Vesa Koivukangas (Surgery Research Unit, Medical Research Center Oulu. University Hospital and University of Oulu), Arto Kokkola (Department of Surgery, University of Helsinki and Helsinki University Hospital), Simo Laine (Division of Digestive Surgery and Urology, Turku University Hospital), Elina Lietzen (Division of Digestive Surgery and Urology, Turku University Hospital), Johanna Louhimo (Department of Surgery, University of Helsinki and Helsinki University Hospital), Sanna Meriläinen (Surgery Research Unit, Medical Research Center Oulu. University Hospital and University of Oulu), Vesa-Matti Pohjanen (Cancer and Translational Medicine Research Unit, Medical Research Center Oulu, University of Oulu and Oulu University Hospital), Tuomo Rantanen (Department of Surgery, University of Eastern Finland and Kuopio University Hospital), Anna Junttila (Division of Digestive Surgery and Urology, Turku University Hospital), Ari Ristimäki (Department of Pathology, HUSLAB, HUS Diagnostic Center, Helsinki University Hospital and University of Helsinki, Applied Tumor Genomics Research Program, Research Programs Unit, Faculty of Medicine, University of Helsinki), Jari Räsänen (Department of General Thoracic and Oesophageal Surgery, Heart and Lung Centre, University of Helsinki and Helsinki University Hospital,), Juha Saarnio (Surgery Research Unit, Medical Research Center Oulu. University Hospital and University of Oulu), Eero Sihvo (Department of Surgery, Central Finland Central Hospital, Jyväskylä), Vesa Toikkanen (Department of Cardiothoracic Surgery, Heart Center, Tampere University Hospital and University of Tampere), Tuula Tyrväinen (Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital), Antti Valtola (Department of Surgery, University of Eastern Finland and Kuopio University Hospital)
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This article refers to: Putila E, Helminen O, Helmiö M, et al. Postoperative complications after neoadjuvant chemotherapy compared to upfront surgery in gastric adenocarcinoma, a population-based nationwide study in Finland. Annals Surgical Oncology. (2023). https://doi.org/10.1245/s10434-023-14813-5.
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Emilia, P., Helminen, O., Kauppila, J.H. et al. ASO Author Reflections: Neoadjuvant Chemotherapy Does not Increase Postoperative Complications Compared with Upfront Surgery in Gastric Adenocarcinoma: A Population-Based, Nationwide Study in Finland. Ann Surg Oncol 31, 2711–2712 (2024). https://doi.org/10.1245/s10434-023-14886-2
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DOI: https://doi.org/10.1245/s10434-023-14886-2