New directions in the neoadjuvant treatment of tumors of the upper GI tract

Despite numerous phase-II and phase-III studies investigating neoadjuvant t reatment in esophageal and gastric cancer, the value of multimodal therapy in these tumors is not clearly defined yet. One reason are the different st udy entry criteria and different staging modalities in the investigations p ublished so far. Concerning esophageal cancer, neoadjuvant chemotherapy doe s not yet have a definite role after several phase-III studies. It may be t hat this treatment should only be inaugurated in innovative protocols. Furt hermore, in esophageal cancer it is proven that chemoradiation is superior to radiation alone in the neoadjuvant setting. Following neoadjuvant chemor adiation, there is a distinct trend in favor of multimodal therapy. In the case of locally advanced squamous cell carcinoma of the esophagus, neoadjuv ant chemoradiation offers 30 %-60 % of the patients the possibility for a c omplete resection (UICC-RO); however, this is accompanied by increased post operative morbidity and mortality. In gastric cancer, neoadjuvant chemother apy is still an experimental approach. Intraperitoneal chemotherapy has fai led to show any benefit in Western trials. Clinically related research is c oncentrating on the problem of distinguishing responder from non-responder at the beginning of the therapy. First results indicate that with molecular markers, response might be predicted before therapy. Using 18-FDG PET, it could be possible that the response can be recognized after only 1 week of treatment, opening the door to early response evaluation. New therapeutics like monoclonal antibodies for adjuvant therapy, which is again under discu ssion in gastric cancer, are only in phase-I studies.