MULTIMODAL THERAPY FOR TUMORS OF THE UPPE R GASTROINTESTINAL-TRACT

Adjuvant and neoadjuvant therapeutic principles have in recent years r eceived increasing attention in the management of patients with carcin oma of the upper gastrointestinal tract. A series of randomized prospe ctive trials has demonstrated that adjuvant postoperative radiation or chemotherapy does not result in a convincing survival advantage after complete tumor resection in gastric or esophageal cancer. The availab le data on the role of neoadjuvant preoperative therapy in these patie nts as yet permit no conclusion. While neoadjuvant therapy may reduce the tumor mass in a substantial portion of patients, a series of rando mized controlled trials has shown that, compared to primary resection, a multimodal approach does not result in a survival benefit in patien ts with loco-regional, i.e. potentially resectable, tumors. In contras t, in patients with locally advanced tumors, i.e. tumors for which com plete removal with primary surgery appears unlikely, neoadjuvant thera py increases the chance for complete tumor resection on subsequent sur gery. However, only patients with objective histopathologic response t o preoperative therapy appear to benefit from this approach. Compared to preoperative chemotherapy alone, combined radio-chemotherapy increa ses the rate of response, particularly in squamous cell esophageal can cer, but may also increase postoperative morbidity and mortality. Neoa djuvant therapy should therefore currently only be performed in experi enced centers within the context of prospective clinical trials. The i dentification of factors that would allow prediction of response to ne oadjuvant or adjuvant therapy is the focus of ongoing studies.