THE PLACE OF ADJUVANT AND NEOADJUVANT CHE MOTHERAPY IN THE TREATMENT OF GASTRIC-CANCER

The incidence of gastric adenocarcinoma has decreased dramatically in most Western countries over the past five decades. However, the five-y ear survival rate remains poor and late diagnosis is one of the main r easons for the lack of marked improvement in outcome. More than 50% of the patients found to have advanced local (stage T III), or systemic (stage T IV) gastric cancer at the time of diagnosis. This review arti cle examines the current state of chemotherapeutic regimens additive t o surgery, based on a computer-supported literature search (MED-LINE a nd CANCERLIT). Since 1980 15 randomized studies have been performed to evaluate the efficacy of systemic adjuvant chemotherapy. Of these, 13 were published in the Western English Literature and 2 were Japanese studies, encompassing a total of over 2000 patients. In 3 studies adju vant chemotherapy was administered intraperitoneally. An evaluation of these studies failed to demonstrate any advantage for the outcome of chemotherapy on-patients with curative resected gastric carcinoma. Thu s, according to present knowledge, this form of adjuvant treatment can not be recommended for routine clinical management. In order to evalua te the effect of neoadjuvant chemotherapy, 17 randomized studies have been reviewed. In 6 studies (3 Western studies, 3 Japanese studies) ne oadjuvant chemotherapy was investigated in patients with potentially c urative resectable gastric carcinoma. 11 Western studies reported the results of neoadjuvant chemotherapy in cases of locally advanced disea se. It appears that neoadjuvant chemotherapy of locally advanced non-r esectable gastric cancer in patients who do not have distant metastase s and/or ''carcinosis peritonei'' reduces tumor size in 30-40% of the patients, thus enabling radical resection in a second look operation. The efficacy of neoadjuvant chemotherapy in potentially resectable gas tric carcinoma cannot be definitely assessed at the present time since only scant, preliminary findings are available. Future goals for the treatment of gastric carcinoma should include studies evaluating preop erative chemotherapy using effective, but less toxic substances, based on exact tumor-staging by means of endoluminal sonography. Furthermor e, research projects investigating the value of intraperitoneal therap eutic regimens such as hyperthermic chemoperfusion or intraperitoneal instillation of the requisite substances in the prevention of intraper itoneal carcinomatosis and local recurrence will be of great importanc e.