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Neoadjuvant chemotherapy for gastric cancer: Update

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Abstract

Neoadjuvant chemotherapy has recently received increasing attention in an attempt to increase the rate of complete tumor resections, combat systemic metastases, and prolong survival in patients with gastric cancer. The available data indicate that neoadjuvant chemotherapy is feasible and does not increase postoperative morbidity and mortality. Compared to the results that can today be obtained with primary resection and lymphadenectomy, however, preoperative chemotherapy has so far failed to show a clear increase in the rate of complete tumor removal in patients with resectable gastric cancer. In patients with locally advanced or unresectable gastric cancer, preoperative chemotherapy may cause substantial reduction in locoregional tumor mass and thus increase the resection rate. This finding appears to translate into a survival benefit for those who respond to chemotherapy and have subsequent complete tumor resection. Because of severe shortcomings in the study design of the published reports, definite conclusions cannot be drawn from the available studies. Randomized controlled prospective trials are therefore clearly warranted. Exact pretherapeutic tumor staging, standardized resection and lymphadenectomy techniques, diligent evaluation of the resected specimen, and close follow-up are essential when designing these trials to identify subgroups of patients who may benefit from neoadjuvant chemotherapy for gastric carcinoma.

Résumé

On a récemment souligné l'intérêt, chez les patients ayant un cancer gastrique, de la chimiothérapie néoadjuvante pour améliorer le taux de résecabilité complète des tumeurs, pour combattre des métastases systémiques et pour prolonger la survie. En effet, les études disponibles indiquent que la chimiothérapie néoadjuvante est faisable sans augmenter ni la mortalité ni la morbidité. Comparée aux résultats obtenus aujourd'hui par la résection primitive associée à un curage, la chimiothérapie préopératoire, par contre, ne s'est pas montrée capable d'améliorer le taux de résecabilité des tumeurs estimées résécables à priori. Chez le patient ayant un cancer avancé ou non résécable, par contre, la chimiothérapie préopératoire peut réduire considérablement le volume tumoral et augmenter la possibilité de résection. Chez le patient qui répond à la chimiothérapie et qui a, par la suite, une résection complète de la tumeur, la survie apparaît donc améliorée. An raison d'imperfections dans la conception même de certaines de ces études, cependant, il n'est pas possible de tirer des conclusions définitives. Des études contrôlées, et randomisées, sont clairement nécessaires. Un «staging» préthérapeutique exact, une technique de résection et de curage standardisée, une évaluation diligente de la pièce après résection ainsi qu'un suivi rigoureux sont essentiels dans l'élaboration de ces essais pour identifier le sous-groupe de patients ayant un cancer gastrique qui pourraient bénéficier de la chimiothérapie néoadjuvante.

Resumen

En tiempos recientes ha merecido creciente atención la quimioterapia neoadyuvante en un intento por aumentar las tasas de resecciones tumorales completas, combatir metástasis sistémicas y prolongar la supervivencia en pacientes con cáncer gástrico. La información disponible indica que la terapia neoadyuvante es factible y no aumenta la morbilidad ni la mortalidad postoperatorias. En comparación con los resultados que actualmente se obtienen con la resección primaria y la linfadenectomía, la quimioterapia preoperatoria hasta ahora, sin embargo, ha fallado en cuanto a demostrar un claro incremento en la rata de resección completa del tumor en los pacientes con cáncer gástrico resecable. En los pacientes con cáncer gástrico localmente avanzado o no resecable, la quimioterapia preoperatoria puede causar una reducción sustancial de la masa local-regional, y, por lo tanto, un incremento en la tasa de resección. Esto parece traducirse en un beneficio de supervivencia en aquellos pacientes que responden a la quimioterapia y que luego son sometidos a una resección completa de su tumor. Debido a severas limitaciones en el diseño de los informes publicados, no es posible derivar conclusiones definitivas a partir de la información disponible. Por lo tanto, aparece clara la necesidad de realizar ensayos clínicos prospectivos y randomizados. Una muy exacta estadificación tumoral preterapéutica, la resección estandarizada y la técnica de linfadenectomía, el examen meticuloso del espécimen resecado y un cuidadoso seguimiento son esenciales cuando se diseñen ensayos clínicos y se pretenda identificar subgrupos de pacientes que puedan beneficiarse de quimioterapia neoadyuvante para el carcinoma gástrico.

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Authors and Affiliations

  1. Department of Surgery, Technische Universität München, Ismaningerstrasse 22, D-81675, Munich, Germany

    U. Fink M.D., H. J. Stein M.D. & C. Schuhmacher M.D.

  2. Westdeutsches Tumorzentrum, Universitätklinikum Essen, Essen, Germany

    H. J. Wilke M.D.

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  1. U. Fink M.D.
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Fink, U., Stein, H.J., Schuhmacher, C. et al. Neoadjuvant chemotherapy for gastric cancer: Update. World J. Surg. 19, 509–516 (1995). https://doi.org/10.1007/BF00294711

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