Preoperative chemotherapy for unresectable gastric cancer

Even with extended surgery, including systematic lymphadenectomy of the lymph node compartment II, only half of the patients with locally advanced gastric cancer (LAGC), which comprises stages IIIA, IIIB, and IV, undergo a macroscopic and microscopic tumor-free resection (i.e., R0 resection, according to UICC 1987/AICC 1988). An improvement of this situation is best accomplished by preoperative treatment modalities to increase the R0 resection rate and by preoperative and postoperative treatment to reduce local recurrences and distant metastases. For LAGC, which includes approximately two-thirds of patients with locoregionally confined tumors, preoperative chemotherapy (CTx) represents a promising approach. Among a group of patients with surgically or clinically staged unresectable LAGC, approximately half underwent R0 resection after down-staging induced by active modern CTx. The long-term survival of these patients seems to be improved. Even in patients who had primarily unresectable tumors as defined by an explorative laparotomy, the long-term survival was about 20% after preoperative CTx and subsequent surgery. Based on these experiences, randomized trials investigating preoperative CTx versus surgery alone are clearly needed to define whether such an approach has an impact on R0 resection rates and survival of patients with LAGC. Preconditions for such trials are clinical staging procedures, including endoscopic ultrasonography (T category) and surgical laparoscopy plus lavage (excluding peritoneal carcinomatosis), and a standardized surgical procedure.