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Journal of Clinical Oncology, Vol 23, No 16 (June 1), 2005: pp. 3870 © 2005 American Society of Clinical Oncology. DOI: 10.1200/JCO.2005.05.204
Preoperative Radiochemotherapy in Gastric Cancer: Another Ongoing Shift From Adjuvant to Neoadjuvant?Radiation Oncology Service, Geneva University Hospital, Geneva, Switzerland To the Editor: I read with interest the article by Ajani et al on preoperative radiochemotherapy in gastric cancer published in the July 15, 2004, issue of the Journal of Clinical Oncology.1 Since a similar experience published recently by our Geneva group2 apparently escaped the authors' attention, I thought it worthwhile to call it to the attention of the Journal's readers. Indeed, the approach and the chemotherapeutic agents used were quite similar, though the schedule of administration was different. In both series, preoperative radiochemotherapy was associated with remarkably low locoregional recurrence rates, with the peritoneum becoming a major site of failure. The survival rates were also comparable, with approximately 40% overall survival at 5 years. However, as the rate of distant metastases in the Ajani et al series remained very high (distant 45% + peritoneum 21%), one might question the value of upfront chemotherapy. Moreover, this approach was associated with two treatment-related deaths (7%), making it difficult to recommend. Based on the results of the two series, future trials might favor concomitant radiochemotherapy using newer active drugs such as taxanes, and the use of intraperitoneal chemotherapy under hyperthermic conditions might be envisioned in case of peritoneal involvement.3 Finally, I seriously question the authors' conclusions that major tumor response translates directly into a significant survival advantage. In fact, the overall survival and disease-free survival rates of the whole group were not different compared with the rates reported in the randomized trial of Macdonald et al4 using postoperative radiochemotherapy. Indeed, good response may reflect less aggressive biologic characteristics of the particular tumor, whose outcome would be favorable regardless of response to adjuvant treatment. The latter argument is clearly supported by the results of the recent randomized trial on preoperative radiochemotherapy in esophageal carcinomas, where similar overall and event-free survival rates were reported.5 Nevertheless, the results of the Ajani et al add to the evidence suggesting that neoadjuvant radiochemotherapy may be a good option to deal with the problems associated with administration of adjuvant treatment in some tumor locations where we know that surgery alone is inadequate. Author's Disclosures of Potential Conflicts of Interest The author indicated no potential conflicts of interest. REFERENCES
1. Ajani JA, Mansfield PF, Janjan N, et al: Multi-institutional trial of preoperative chemoradiotherapy in patients with potentially resectable gastric carcinoma. J Clin Oncol 22:2774-2780, 2004
2. Roth AD, Allal AS, Brundler MA, et al: Neoadjuvant radiochemotherapy for locally advanced gastric cancer: A phase l-ll study. Ann Oncol 14:110-115, 2003 3. Glehen O, Mohamed F, Gilly FN: Peritoneal carcinomatosis from digestive tract cancer: New management by cytoreductive surgery and intraperitoneal chemohyperthermia. Lancet Oncol 5:219-228, 2004[CrossRef][Medline]
4. Macdonald JS, Smalley SR, Benedetti J, et al: Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med 345:725-730, 2001
5. Lee JL, Park SI, Kim SB, et al: A single institutional phase III trial of preoperative chemotherapy with hyperfractionation radiotherapy plus surgery versus surgery alone for resectable esophageal squamous cell carcinoma. Ann Oncol 15:947-954, 2004
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Copyright © 2005 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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