Cancer of the Stomach and Gastroesophageal Junction
Leonard L. Gunderson, John H. Donohue, Steven R. Alberts, Jonathan B. Ashman and Dawn E. Jaroszewski
Summary of Key Points
Staging Evaluation
• Staging should always include history and physical examination, complete blood cell count, liver chemistries, chest x-ray film, endoscopy with biopsy, ultrasound (determine degree of direct tumor extensions), and computed tomography (CT) of the abdomen (define extragastric disease).
• Additional studies that may help define extent of disease include upper gastrointestinal imaging, CT of the chest (for gastroesophageal junction [GEJ] lesions), laparoscopy (to rule out peritoneal seeding or early liver metastases), and positron emission tomography.
Primary Therapy
• Surgical resection is the primary therapy of resectable gastric and GEJ cancers.
• Cure rates of 80% or higher are achieved only with early lesions (patients with nodes negative, confined to mucosa or submucosa), which are uncommon in the United States.
• Role for extended node dissection has not been found in randomized trials.
Adjuvant Therapy
• Adjuvant therapy (chemotherapy, irradiation) is indicated on the basis of patterns of relapse and survival results with surgery alone (high rates of local-regional relapse and distant metastases).
• Adjuvant chemotherapy has a modest, significant benefit and has become the standard in Asia.
• Irradiation alone reduced local-regional relapse and improved overall survival (OS) in a Beijing trial of 370 patients testing preoperative irradiation versus surgery alone (5-year OS 30% vs. 20%, P = 0.009).
• The U.S. intergroup phase III trial of 556 patients found a survival benefit for combined-modality postoperative irradiation plus chemotherapy versus surgery alone (3-year relapse-free survival 48% vs. 31%, P = 0.001; 3-year OS 50% vs. 41%, P = 0.005).
• A British phase III trial of 503 patients demonstrated a survival advantage for perioperative ECF chemotherapy (epirubicin, cisplatin, 5-fluorouracil [5-FU]) when compared with surgery alone (5-year OS 36% vs. 23%, P = 0.009).
• A French phase III trial of 224 patients demonstrated a survival advantage for perioperative cisplatin and 5-FU compared with surgery alone (5-year OS 38% vs. 24%, P = 0.02).
• The POET trial of 120 patients with GEJ lesions tested preoperative chemotherapy versus chemoradiotherapy (CRT); outcomes trends favored preoperative CRT over chemotherapy alone for both OS (P = 0.07) and local control (P = 0.06).
Locally Advanced Disease (Borderline Resectable/Unresectable)
• Combined external beam radiation therapy (EBRT) plus chemotherapy or intraoperative radiation therapy (IORT) produced long-term survival in 10% to 20% of patients in most randomized and nonrandomized trials.
