CURATIVE TREATMENT OF GASTROINTESTINAL CANCER .2. SURGICALLY DIRECTEDADJUVANT REGIONAL CHEMOTHERAPY

The role of precision oncologic surgery for resectable gastrointestina l cancer as a best chance for curative treatment was discussed in the Part I of this review. Nevertheless, optimal surgical technique alone may not decrease to the lowest possible level the incidence of local a nd regional recurrence. Early results from randomized trials with regi onal, mainly intraperitoneal chemotherapy, demonstrated that the natur al history of gastrointestinal cancer may be altered and the incidence of peritoneal dissemination diminished. The effect of such therapy is distribution and exposure dependent. Hence, intraoperative and early postoperative administration is the best way for prophylaxis of perito neal dissemination. Careful assessment of the risk factors of the live r metastases during pathologic examination of resected specimen may he lp to select patients and thus increase the effect of intraportal or p rolonged early intraperitoneal chemotherapy. Systemic chemotherapy may be indicated in patients with major involvement of lymph nodes (> 25% of those examined). Targeted drug delivery by special vehicles to the lymph nodes should be further explored. Thus, a package of multiple, simultaneous and perioperative adjuvant chemotherapies focused on anat omic sites at high risk for surgical treatment failure becomes a treat ment strategy in need of extensive testing, revision and more testing. Surgeons must play an active role in initiating and customizing adjuv ant regional antitumor therapy in order to improve survival through an increment of positive changes in the incidence of local, peritoneal a nd lympho-hematogenous recurrence.