Neoadjuvant Therapy of Gastric Cancer: A Decisive Step Forward

Abstract

Background: Although its incidence has been steadily decreasing in Western countries, gastric cancer remains a leading cause of cancer deaths worldwide. The detection rate of early-stage cancers is improving; nevertheless, the majority of cases is still diagnosed at later stages with a poor prognosis. Furthermore, the results that can be achieved with surgery have reached a plateau of effectiveness. Summary: Neoadjuvant chemotherapy was successfully introduced first in patients with non-curatively resectable disease. In the last decade, neoadjuvant chemotherapy has also been established in potentially curatively resectable cases and has become the state-of-the-art treatment. Esophagogastric junction (EGJ) tumors are not optimally treated with chemotherapy alone, and combined radiochemotherapy (RCT) seems to yield superior outcomes. Key Message: The use of neoadjuvant therapy has been successfully established in patients with curatively resectable disease. Neoadjuvant chemotherapy is now a cornerstone in the treatment of gastric cancer and cancer of the EGJ, although further work is needed in order to define the optimal combination regimen. Practical Implications: Neoadjuvant chemotherapy is currently the gold standard for the treatment of gastric cancer and cancer of the EGJ. Several independent studies have shown the benefits of using combination regimens that included cisplatin and 5-fluorouracil, though recently the use of the EOX (epirubicin, oxaliplatin and capecitabine) regimen has been widely accepted in this setting. Tumors of the EGJ benefit from neoadjuvant treatment with combined RCT. It should be noted that the optimal neoadjuvant regimen in EGJ tumors has not yet been defined, and the survival advantage of neoadjuvant RCT over neoadjuvant chemotherapy remains to be established in this patient population.

Does neoadjuvant/perioperative chemotherapy improve overall survival for T2N0 gastric adenocarcinoma?

“…While NAC has become a standard of care for patients with gastric and esophagogastric cancer, some studies support omission of NAC, and it is unclear which specific stages, including T2N0, derive OS benefit . In a recent analysis of the MAGIC trial, Smyth et al concluded that the presence of lymph node metastases and not cPR to chemotherapy was the only independent predictor of OS after chemotherapy plus resection, further raising question as to whether NAC provides OS benefit based on T stage .…”

Efficacy and safety of nanosomal docetaxel lipid suspension based chemotherapy in gastric and gastroesophageal junction adenocarcinoma

“…The current study presents the findings of NDLS based chemotherapy in patients with gastric and GEJ cancer in neoadjuvant and metastatic settings. Neoadjuvant treatment remains the gold standard for the treatment of locally advanced gastric cancer, which aims at 'downstaging' the tumor and eliminating the spread of tumor cells or lymph node metastases (36). The available evidence suggests a role for neoadjuvant docetaxel-based chemotherapy in downstaging the cancer, achieving complete surgical resection and probably improving the outcome in patients with locally advanced GAC (37).…”