Preoperative chemotherapy

E. Strong (ed.). Gastric cancer. Principles and practice. Springer (2015)

A strategy of perioperative chemotherapy is the predominant approach in Europe and increasingly in the USA, based primarily on the phase III Medical Research Council Adjuvant Gastric Infusional Chemotherapy (MAGIC) trial performed in the UK [14]. This trial randomized 503 patients with gastric cancer to three cycles each of preand postoperative epirubicin/cisplatin/5fluorouracil or 5-FU (ECF) and surgery or surgery alone. Perioperative chemotherapy resulted in significant improvement in 5-year OS (36 vs. 23%, p = 0.009), establishing this regimen as a standard of care.

A similar degree of benefit was also noted in the contemporaneous French FFCD 9703 trial of 224 patients with esophagogastric adenocarcinoma [15]. Patients were randomized to six cycles of perioperative 5-FU/cisplatin followed by surgery versus surgery alone. Perioperative chemotherapy on this trial was associated with a significant improvement in 5-year disease-free survival (DFS; 34 vs. 19%, p = 0.003) and OS (38 vs. 24%, p = 0.02). Although comparisons between different clinical trials must be made cautiously, the survival benefit seen with 5-FU/cisplatin on this trial appears to be nearly identical to that seen with ECF in the MAGIC trial. As such, a 5-FU/platinum doublet is also an option in the perioperative setting, especially for patients who are not candidates for or have poor tolerance of the addition of an anthyracycline.

On the other hand and most recently, the European EORTC 40954 trial evaluated a strategy of preoperative 5-FU/leucovorin/cisplatin in 144 patients with GEJ and gastric adenocarcinoma [16]. The trial was stopped because of poor accrual, which limits the power of the study, and no differences in survival were detected. These data are summarized in Table 21.1.

Table 21.1. Results of phase III preor perioperative chemotherapy trials in gastric and GE junction cancer

Gastric cancer. Principles and practice (2015) T 21.1

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