Adjuvant therapy in esophagogastric adenocarcinoma: controversies and consensus

Esophagogastric (EG) adenocarcinomas are aggressive malignancies. Although uncommon in the United States, gastric cancer is endemic in East Asia. In this review we focus on perioperative strategies for locally advanced EG adenocarcinomas.

We summarized the results of completed phase III trials of perioperative therapy for locally advanced adenocarcinomas of the esophagus, gastroesophageal (GE) junction, or stomach. We also reviewed ongoing clinical trials.

In the adjuvant setting following surgery, validated approaches include chemoradiation with a fluoropyrimidine or chemotherapy (using a fluoropyrimidine with or without platinum compound). In the neoadjuvant setting, some trials have shown a benefit for perioperative chemotherapy. Trials in esophageal and GE junction adenocarcinomas have also shown improved outcomes with preoperative chemoradiation, which, on the basis of a phase III trial and large meta-analysis, may be superior to preoperative chemotherapy. Changes on positron emission tomography (PET) scans following chemotherapy or chemoradiation have been shown to be prognostic, and the use of PET imaging to guide the choice of chemotherapy with concurrent radiation is being evaluated. Other trials are combining targeted therapies with standard treatments.

Numerous adjuvant and pre-/perioperative strategies have now been shown to improve survival by approximately 15% compared to surgery alone. Ongoing trials will hopefully clarify the relative superiority of such approaches, the ability of PET to direct therapy, and the role of targeted agents in treating locally advanced tumors.