Resected gastric cancer with D2 dissection: advances in adjuvant chemoradiotherapy and radiotherapy techniques

Abstract

Surgery is the main treatment option for locally advanced gastric cancer. D2 dissection has been recommended worldwide as standard lymphadenectomy for resectable gastric cancer. Furthermore, the role of peri- or postoperative chemotherapy for D2-dissected gastric cancer has been established in both Western and European countries. It has been disputed whether adding radiotherapy to chemotherapy could further benefit those patients. Until recently, studies from Korea and China may have made it clear. In North America, however, the INT-0116 trial does not rule out that chemoradiotherapy is effective in patients with D2 dissection, but the ongoing CRITICS trial will, hopefully, clarify this. In addition, literature published in the past decade supports the theory that improved radiotherapy techniques are likely to accurately deliver radiation dose and significantly reduce radiation toxicity. Finally, the status of E2F-1 and HER-2 may be associated with efficacy of radiotherapy based on retrospective studies.

Keywords:

• adjuvant
• biomarker
• chemoradiotherapy
• D2 dissection
• efficacy
• gastric cancer
• radiotherapy technique

Acknowledgement

This study was granted from the National Basic Research Program of China (no. 2011CB935800).

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.

No writing assistance was utilized in the production of this manuscript.

Key issues

• D2 lymph node dissection has been recommended as standard lymphadenectomy for resectable gastric cancer in both East Asia and Europe, leading to a worldwide consensus.

• The role of adjuvant chemotherapy alone for D2-dissected gastric cancer has been well defined.

• Adding radiotherapy to chemotherapy might significantly improve disease-free survival and reduce locoregional recurrence for locally advanced D2-dissected gastric cancer (especially with positive lymph nodes) in East Asia, whereas the definite conclusion may be confirmed by the results of ARTIST-II in Korea, an ongoing Phase III trial focusing on pathological node-positive patients.

• In North America, the INT-0116 trial does not rule out that chemoradiotherapy is effective in gastric cancer patients with D2 dissection, but the ongoing CRITICS trial will, hopefully, clarify this.

• Advanced radiotherapy techniques provide opportunities to veritably delineate target volume of tumor, to accurately deliver radiation dose, and to significantly reduce radiation toxicity for D2-dissected gastric cancer in the postoperative setting.

• HER2 and E2F-1, as molecular biomarkers, can potentially predict efficacy of radiotherapy in patients with resected gastric cancer