Chemoradiotherapy after Surgery Compared with Surgery Alone for Adenocarcinoma of the Stomach or Gastroesophageal Junction

Macdonald, John S.; Smalley, Stephen R.; Benedetti, Jacqueline; Hundahl, Scott A.; Estes, Norman C.; Stemmermann, Grant N.; Haller, Daniel G.; Ajani, Jaffer A.; Gunderson, Leonard L.; Jessup, J. Milburn; Martenson, James A.

doi:10.1056/nejmoa010187

Cited by 3,117 publications

(2,466 citation statements)

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“…However, the sensitivity analysis as performed in the current study suggests that the survival advantages of preoperative RT remained clinically Second, an important caveat of the current study is that the SEER database does not provide data regarding chemotherapy. However, both preoperative and postoperative RT are almost always administered concurrently with chemotherapy, [1][2][3][4][5]7,26,28 and therefore it is less likely that the lack of chemotherapy data is a source of bias in the concurrent setting. In addition, chemotherapy itself can be a possible cause of cardiopulmonary mortality.…”

Section: Discussionmentioning

confidence: 99%

“…[1][2][3][4][5][6] In the subset of patients with tumors of the gastroesophageal junction, CRT delivered postoperatively has also demonstrated a survival benefit. 7 To the best of our knowledge, no randomized controlled trials currently exist that compare the outcomes of the sequencing of CRT in relation to surgery in patients with esophageal cancer.…”

Section: Introductionmentioning

confidence: 99%

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The impact of radiation therapy sequencing on survival and cardiopulmonary mortality in the combined modality treatment of patients with esophageal cancer

Wojcieszynski

Berman²,

Wan³

et al. 2013

Cancer

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BACKGROUND: The addition of chemoradiation (CRT) to surgery has been shown to improve survival in patients with esophageal cancer. In the current study, the authors determined whether the sequencing of CRT has an effect on survival and cardiopulmonary mortality in patients with esophageal cancer. METHODS: Patients with the following inclusion criteria were identified within 17 Surveillance, Epidemiology, and End Results registries from 1988 through 2007: adenocarcinoma or squamous cell carcinoma of the esophagus and having undergone esophagectomy. Patients who died within 90 days of surgery were excluded. Demographic, tumor, and survival data were compared between patients receiving preoperative and postoperative RT. Cox proportional hazards regression models were calculated to identify parameters associated with cause-specific survival and overall survival. A competing risk analysis was performed to account for death due to esophageal cancer in the calculation of cardiopulmonary mortality. RESULTS: Of 5512 patients, 1881 received preoperative RT, 901 received postoperative RT, and 2730 did not receive RT. Patients receiving preoperative RT had improved 5-year cause-specific survival (41% vs 31%; P < .0001) and overall survival (33% vs 23%; P < .0001) compared with those receiving postoperative RT. No differences in adjusted cardiopulmonary mortality were found between patients who received RT versus those who did not (8% vs 10% at 10 years; hazards ratio [HR] KEYWORDS: esophageal neoplasms, combined modality therapy, radiation oncology, survival, heart diseases, lung diseases. INTRODUCTIONIn patients with locally advanced esophageal cancer, the addition of chemoradiation (CRT) to surgery has shown improvements in overall survival (OS) when given preoperatively. [1][2][3][4][5][6] In the subset of patients with tumors of the gastroesophageal junction, CRT delivered postoperatively has also demonstrated a survival benefit. 7 To the best of our knowledge, no randomized controlled trials currently exist that compare the outcomes of the sequencing of CRT in relation to surgery in patients with esophageal cancer.Preoperative CRT is preferred over postoperative treatment in patients with other gastrointestinal malignancies such as rectal cancer, in whom preoperative CRT has been demonstrated to have a superior locoregional control rate, toxicity profile, and survival rate. 8,9 It is postulated that preoperative treatment is favored because of tumor downstaging and smaller radiation treatment fields. We hypothesized that preoperative RT is associated with decreased cardiopulmonary mortality from lower RT doses to the heart and lungs as well as improved survival outcomes compared with postoperative RT in patients with esophageal cancer.Using the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database, we assessed differences in survival outcomes between patients treated with preoperative RT and those treated with postoperative RT and analyzed the effect of RT on heart and lung morbidity a...

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

The impact of radiation therapy sequencing on survival and cardiopulmonary mortality in the combined modality treatment of patients with esophageal cancer

Wojcieszynski

Berman²,

Wan³

et al. 2013

Cancer

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“…However, in the chemotherapy arm only 43% of patients completed the postoperative planned programme, probably as a consequence of the fact that gastric cancer patients have been often shown to be hardly compliant to postoperative chemotherapy . On the other hand, it has also been previously reported that a chemoradiotherapy adjuvant approach may improve the outcome of radically resected gastric cancer by lowering the incidence of local relapse (Macdonald et al, 2001). The availability of various and different treatment options has consequently reintroduced the crucial question of an accurate treatment selection and a correct definition of high-risk categories, which may help identifying subgroups of patients benefiting more from additional medical treatments after (or before) radical surgery.…”

Section: Discussionmentioning

confidence: 99%

“…Although most clinical trials investigating adjuvant chemotherapy generated inconclusive results (Hermans et al, 1993;Earle andMaroun, 1999, Cascinu et al, 2005), it has been reported that a chemoradiotherapy adjuvant approach may improve the outcome of radically resected gastric cancer by lowering the incidence of local relapse (Macdonald et al, 2001).…”

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confidence: 99%

Lymphatic, blood vessel and perineural invasion identifies early-stage high-risk radically resected gastric cancer patients

et al. 2006

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The availability of different treatment options for radically resectable gastric cancer reopened the question of treatment selection and correct definition of high-risk categories. Lymphatic, blood vessel and perineural invasion (LBVI/PNI) seem to possess the necessary potential to provide useful information for the clinical management of this disease. Seven hundred and thirty-four patients with advanced gastric cancer who underwent curative gastrectomy were analysed according to the presence of LBVI/PNI. Patients were divided into two groups: group A for patients with LBVI/PNI (189 patients 26%) and group B for patients without LBVI/PNI (545 patients, 74%). The disease-free survival (DFS) for patients in group A was 32.1 months, whereas it was not reached for patients in group B (P ¼ 0.0001); the median overall survival was 45.5 months for patients in group A, whereas it was not reached for patients in group B (P ¼ 0.0001). At multivariate analysis, the presence of LBVI/PNI appeared an independent prognostic factor for DFS and OS. Our results were confirmed in subgroup analysis, separately considering stage I and early gastric cancer patients with and without LBVI/PNI. Taken together, our findings suggest the importance of LBVI/PNI in gastric cancer as it may provide additional information for identifying patients at high risk, who may be candidates for further medical treatment after or before surgery.

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“…Treatment results of advanced gastric cancer have been improved by the introductions of lymph node dissection and postoperative adjuvant chemotherapy and radiation therapy [1][2][3]. However, more than 50% of potentially curable advanced gastric cancer patients died of peritoneal recurrence [4].…”

Section: Introductionmentioning

confidence: 99%

Safety and efficacy of bidirectional chemotherapy for treatment of patients with peritoneal dissemination from gastric cancer: Selection for cytoreductive surgery

Yonemura¹,

Endou

Shinbo

et al. 2009

Journal of Surgical Oncology

116

112

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There is no standard treatment for peritoneal carcinomatosis (PC) from gastric cancer. New bidirectional chemotherapy (neoadjuvant intraperitoneal-systemic chemotherapy protocol (NIPS)) was developed. The aim of the present study was to assess the safety and efficacy of NIPS and to show the selection for cytoreductive surgery on PC from gastric cancer. Seventy-nine patients with PC from gastric cancer were treated with NIPS. A peritoneal port system was introduced into the abdominal cavity. The peritoneal wash cytological examination through a port was done before and after NIPS. The patients were treated with oral TS-1 twice a daily for 21 days, followed by a 1-week rest. On day 1, 8, and 15 from the start of oral TS-1 administration, 30 mg/m 2 of Docetaxel and 30 mg/m 2 of cisplatinum with 500 ml of saline were introduced into the peritoneal cavity through the port. A median course of oral TS-1 was 2.1 course and a median time of IP chemoterapy was 5.8. Peritoneal free cancer cells (PFCCs) had been detected in 65 (82.2%) patients before NIPS, and the positive cytology changed to be negative in 41 (63.0%) patients after NIPS. After NIPS, 41 patients underwent laparotomy, and complete cytoreduction was done in 32 (78%) patients. Complete cytoreduction was done in 27 (51.9%) of 52 patients with negative cytology but in only 4 (14.8%) of 27 patients with positive cytology (P < 0.001). Patients with negative cytology after NIPS survived significantly longer than those with positive cytology. The adverse effects after NIPS were mild and there was no treatment-related deaths. The grade 3/4 hematological adverse effects were found in 2 (2.6%) patients. Grade 3 renal toxicity and port site infection was found in three patients, respectively. NIPS using a port system is a safe and effective treatment for PC. Peritoneal wash cytology through a port system is a good indicator to select the patients to perform cytoreductive surgery.

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Chemoradiotherapy after Surgery Compared with Surgery Alone for Adenocarcinoma of the Stomach or Gastroesophageal Junction

Abstract: Postoperative chemoradiotherapy should be considered for all patients at high risk for recurrence of adenocarcinoma of the stomach or gastroesophageal junction who have undergone curative resection.

Cited by 3,117 publications

References 21 publications

The impact of radiation therapy sequencing on survival and cardiopulmonary mortality in the combined modality treatment of patients with esophageal cancer

The impact of radiation therapy sequencing on survival and cardiopulmonary mortality in the combined modality treatment of patients with esophageal cancer

Lymphatic, blood vessel and perineural invasion identifies early-stage high-risk radically resected gastric cancer patients

Safety and efficacy of bidirectional chemotherapy for treatment of patients with peritoneal dissemination from gastric cancer: Selection for cytoreductive surgery

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