[Preoperative downstaging in advanced stomach carcinoma. Wishful thinking or reality]

By the time it is diagnosed, gastric carcinoma is usually already advanced and, as a result, has a poor prognosis. Surgery, with complete (R0) resection of the tumor, is the only chance of cure for this disease. However, in locally advanced gastric carcinoma this is only possible in approximately half of all cases. In order to help improve the prognosis of patients with advanced stage carcinomas, the concept of multimodal therapy is presently being evaluated. The results of studies of postoperative adjuvant therapy have been contradictory, with the result that no indication for such treatment outside of study protocols presently exists. Recently, preoperative application of chemotherapy, the so-called "neoadjuvant" therapy concept, has become increasingly important, since it has been demonstrated that, in individual cases, tumors thought to be primarily unresectable have been able to be completely resected after chemotherapy. Based on the available studies, one can assume that, in a subgroup of patients with not yet identified favorable tumor biologic characteristics, a true down staging of the tumor occurs. To what extent a preoperative "over-staging" may be a factor can only be estimated statistically, since the presently available methods for clinical estimation of tumor stage are never as accurate as the final histopathologic evaluation. Since the recently started, randomized multicenter study under the auspices of the EORTC compares surgery alone with a combination of surgery and preoperative chemotherapy in locally advanced gastric carcinoma, information will soon be available which will help clarify the effectiveness of this therapy concept.