Background: The role of adjuvant chemoradiation for gastric cancer after gastrectomy was first reported by the US Intergroup 0116 study. Recently, another randomized controlled trial has also indicated a survival benefit with the use of perioperative neoadjuvant chemotherapy for patients with locally advanced disease.
Methods: To compare the efficacy of the two treatment regimens, we reviewed the demographic features, treatment results and survival outcomes of 2 cohorts of patients with resectable T3 gastric adenocarcinoma managed in our institue in two different time slots. For the 1st cohort (1998-2000), all patients with T3 disease as confirmed by staging laparoscopy were prescribed with 2 cycles of 3-week ECF (Royal Marsden regimen). It was followed by a standard D2 radical gastrectomy with roux-en-Y reconstruction. Chemo-response was measured by pre and post-chemotherapy CT scan volumeometry. For the 2nd cohort (2001-2004), a D2 gastrectomy was first performed, and chemoradiotherapy (CRT) was commenced within 6 weeks after the operation. All patients were followed up on a monthly basis after completion of treatment. Survival analysis was performed using Kaplan-Meier method.
Results: There were 34 patients in each cohort. The age (57.7(SD:9.5) vs 57.9(SD:9.6), p=0.9), gender ratio, KP score, and pre-morbid condition were comparable between the two groups. In the neoadjuvant group, partial response was observed in 13 patients (38%), but 2 patients had progression of disease which was so severe that they could not proceed for the scheduled gastrectomy. One patient developed reactivation of hepatitis and was succumbed to liver failure without gastrectomy. In addition, postoperative anastomotic leak was seen in 2 patients. Both required prolonged hospitalization and 1 needed re-laparotomy for secondary hemorrhage. In the postop CRT group, 30% of patients experienced grade 3 or above acute toxcity, and 1 patient died of neutropenic sepsis. Despite that, 70% patients were able to complete the whole course of therapy. Upon survival analysis, patients treated with postop CRT had a trend of better cumulative 3-year survival when compared to those received the neoadjuvant chemotherapy (64.4% vs 52%, p=0.18), though the difference was not statistically significant. Loco-regional recurrence was also less in the postop CRT group.
Conclusions: There is a trend that postoperative chemoradiotherapy may provide a better survival benefit for patients with gastrectomy of T3 or above. It can also avoid the unnecessary delay in therapy especially in the non-responders. A prospective randomized trial comparing the two regimens may be warranted.