Optimal management of resectable gastric adenocarcinoma

Abstract

The worldwide incidence of gastric adenocarcinoma has rapidly declined in the past century, but gastric cancer remains the fifth most common malignancy in the world. Approximately half of all cases of gastric cancer are diagnosed in Eastern Asia. In this review, we provide an overview of the landmark studies investigating neoadjuvant and adjuvant therapies in resectable gastric cancer and highlight ongoing efforts to define optimal population-adapted management strategies.

Keywords:

• chemoradiation
• chemotherapy
• gastric adenocarcinoma
• locally advanced
• multimodality therapy
• radiation therapy
• respectable
• stomach cancer

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Key issues

• The worldwide incidence of gastric adenocarcinoma has rapidly declined in the past century, but gastric cancer remains the fifth most common malignancy in the world.

• Surgery remains the curative treatment modality for gastric adenocarcinoma; however, in spite of complete resection, survival steeply decreases with stage II disease and beyond.

• Although a significant proportion of patients have recurrence at distant sites, many patients who die from gastric cancer also experience local–regional recurrence. Of note, definition of local–regional recurrence varies among the landmark trials in gastric cancer, with some studies classifying peritoneal and liver recurrences as regional failures [14,15], while others define these as distant failures [16–23].

• Perioperative chemotherapy improves overall survival compared with surgery alone [16,17]. Importantly, in studies that showed a benefit with perioperative chemotherapy, most patients completed the preoperative chemotherapy component, although relatively few were able to receive postoperative chemotherapy.

• Adjuvant chemotherapy improves overall survival compared with surgery alone, even in the setting of D2 lymphadenectomy [16,17].

• Adjuvant chemoradiation therapy confers survival benefit compared with surgery alone, likely by decreasing the risk of local–regional recurrence including peritoneal, liver and nodal recurrences [14,15].

• The ARTIST trial [21,22] suggests that in the setting of D2 dissection, the benefit of chemoradiation may be derived in a subgroup of patients with node positive disease, which will be further investigated by ARTIST II.

• Upcoming trials will compare multimodality regimens and will evaluate the role of neoadjuvant therapy in gastric cancer.