We examined the role of neoadjuvant therapy in downstaging locally advanced gastric cancer.
METHODS: Preoperative staging was performed with a combination of CT scan, endoscopic ultrasound and/or laparoscopy and laparoscopic ultrasound. Patients with T3 and/or N1 disease were eligible for entry. Neoadjuvant therapy consisted of 2 cycles CPT-11 (75mg/m2) with Cisplatin (25mg/m2)weekly X 4 every 6 weeks, followed by resection with D2 lymph node dissection.
RESULTS: 16 patients were entered (3 T3N0, 13 T3N1).One progressed to stage IV disease and did not come to surgery. 15 underwent surgery after completing 76%/69% of the intended induction chemotherapy (CPT-11/cisplatin). 1 patient had stage 4 disease (liver) and underwent a palliative resection. All 14 remaining patients had an R0 resection (2 total, 6 distal and 6 proximal gastrectomies) with an average of 39 (1-121) lymph nodes retrieved. There was one postoperative mortality (pulmonary embolus). One patient had an anastamotic leak,4 patients suffered superficial wound infections and three patients required reoperation (1 leak, 1 gastric atony, 1 unexplained acidosis). The median postoperative length of stay was 9 days (range 3 to 75).Complete TNM pathologic staging was possible in 12/14 patients (2 had inadequate nodal sampling) as summarized in table below. 8/12 patients were downstaged compared to their original preoperative staging. At a median follow up of 12 months, mean survival is 20 months (median not reached) with 4 distant and 1 regional recurrences.
CONCLUSIONS: CPT-11 based neoadjuvant therapy downstages disease as evidenced by the greater percentage of early stage tumors seen after R0 resection in these patients compared to their preoperative staging. Further follow up is necessary to determine the ultimate impact of this combination therapy on overall survival.(Supported in part by Pharmacia Oncology and grants NCI/NIH CA16087 and GCRC M01RR00096)
Postoperative TNM Staging
TNM IA IB II IIIA IIIB IV
n 2 4 2 2 1 1