Original Article Role Of Adjuvant Chemotherapy In A Perioperative Chemotherapy Regimen For Gastric Cancer

Multimodal treatment strategies - perioperative chemotherapy (CTx) and radical surgery - are currently accepted as treatment standard for locally advanced gastric cancer. However, the role of adjuvant postoperative CTx (postCTx) in addition to neoadjuvant preoperative CTx (preCTx) in this setting remains controversial. Proceeds from the sale of this book go to support an elderly disabled person.

One reason for failure to cure solid tumors by surgery appears to be the impossibility of controlling metastases that are present but latent at the time of operation. This failure is a common clinical experience with aggressive neoplasms. but it is not always appreciated in tumors with longer survival times. e. g .• breast and colon cancer. In addition. recent evidence indicates that after resection of a primary tumor micrometas tases from it might be enhanced by suppression of immune and reticu loendothelial functions of the host. Other factors, such as increase of coagulability and stress in the perioperative period, can also promote tumor growth. The development of new metastases might be facilitated by cells forced into the circulation during operative manipulations. Such events could be important for the outcome of treatment and it is suggested that preventive measures should be directed to this systemic component of solid tumors. Radical surgery can reduce the number of tumor cells to a subclinical 3 6 stage (10 to 10 cells) in which chemotherapy might be more effective than in advanced stages. Chemotherapy, on the other hand, might aggravate the surgical morbidity by influencing the wound healing pro cess, by decreasing the immune response, and/or by toxicity to the bone marrow and to the gastrointestinal tract, for example.

Adjuvant chemotherapy is a standard treatment for operable gastric cancer. However, the preferred treatment varies by geographical region. Southwestern Oncology Group (SWOG) conducted a, randomized trial of adjuvant chemotherapy for patients with surgically resected gastric cancer. The 3-year survival rates were 50% in the chemoradiotherapygroup and 41% in the surgery group. The Medical Research Council Adjuvant Gastric Infusional Chemotherapy (MAGIC) trial that compared perioperative chemotherapy with the ECF regimen (epirubicin, cisplatin, and 5-fluorouracil) and patients with surgery alone had a 5-year survival rate of 36 and 23%. The Adjuvant Chemotherapy Trial of TS-1 for Gastric Cancer (ACTS-GC) showed that the 3-year overall survival rate was 80.1% in the S-1 group and 70.1% in the surgery-only group in stage II or III gastric cancer patients who underwent a D2 gastrectomy. An analysis of the Capecitabine and Oxaliplatin Adjuvant Study in Stomach Cancer (CLASSIC) study showed 3-year disease-free survival, 74% in the chemotherapy and surgery group and 59% in the surgery-only group in the patients with stage II,ÄìIIIB gastric cancer who had D2 gastrectomy. In conclusion, for all patients with stage II and III gastric cancer, standard D2 gastrectomy and adjuvant chemotherapy are strongly recommended for improved survival rates.

Included here is a discussion of the pathophysiological aspects and risks of laparoscopic staging (such as trocar metastases) on the basis of international experience.

Gastric cancer has been one of the great malignant scourges affecting man kind for as long as medical records have been kept. Until operative resection pioneered by Bilroth and others became available, no effective treatment was feasible and death from cancer was virtually inevitable. Even with resection by total gastrectomy, the chances of tumor eradication remained small. Over recent years, however, the situation has been changing. Some changes have resulted from better understanding of the disease, early detec tion, and better management techniques with applied clinical research, but the reasons for other changes are poorly understood. For example, the incidence of gastric cancer is decreasing, especially in westernized societies, where it has fallen from one of the most common cancers to no longer being in the top five causes of cancer death. Still it remains the number one killer of adult males in Japan and Korea. Whether the reduced incidence in western societies is a result of dietary changes or methods of food preservation, or some other reason, is as yet uncertain. Improvements in outcome have been reported from mass screening and early detection; more refined techniques of establishing early diagnosis, tumor type, and tumor extent; more radical surgical resection; and resection at earlier stages of disease.

As aging trends in the United States and Europe in particular are strongly suggestive of increasingly older society, it would be prudent for health care providers to better prepare for such changes. By including physiology, disease, nutrition, pharmacology, pathology, radiology and other relevant associated topics, Geriatric Gastroenterology fills the void in the literature for a volume devoted specifically to gastrointestinal illness in the elderly. This unique volume includes provision of training for current and future generations of physicians to deal with the health problems of older adults. It will also serve as a comprehensive guide to practicing physicians for ease of reference. Relevant to the geriatric age group, the volume covers epidemiology, physiology of aging, gastrointestinal physiology, pharmacology, radiology, pathology, motility disorders, luminal disorders, hepato-biliary disease, systemic manifestations, neoplastic disorders, gastrointestinal bleeding, cancer and medication related interactions and adverse events, all extremely common in older adults; these are often hard to evaluate and judge, especially considering the complex aging physiology. All have become important components of modern medicine. Special emphasis is be given to nutrition and related disorders. Capsule endoscopy and its utility in the geriatric population is also covered. Presented in simple, easy to read style, the volume includes numerous tables, figures and key points enabling ease of understanding. Chapters on imaging and pathology are profusely illustrated. All chapters are written by specialists and include up to date scientific information. Geriatric Gastroenterology is of great utility to residents in internal medicine, fellows in gastroenterology and geriatric medicine as well as gastroenterologists, geriatricians and practicing physicians including primary care physicians caring for older adults.

The preferred chemotherapy method for gastric cancer continues to be matter of debate. We performed a meta-analysis to comparing prognosis and safety between perioperative chemotherapy and adjuvant chemotherapy to identify the better chemotherapy option for gastric cancer. Proceeds from the sale of this book go to support an elderly disabled person.

Despite recent advances in adjuvant therapies of cancer, the regi mens of postoperative adjuvant chemotherapy treatment which are presently available fail to cure the majority of cancer patients. Pre operative (neoadjuvant) chemotherapy represents a new approach in drug scheduling, based on sound theoretical, pharmacokinetic, and experimental principles. The preoperative timing of chemotherapy before definitive sur gery is not a minor change in the therapy of cancer. To be successful, large numbers of practitioners and their patients must participate. Substantial alterations of many aspects of the present management of cancer will have to follow. Therefore, before such therapy can be fully and routinely implemented, results of the novel treatment and its rationale have to be carefully evaluated. In preoperative treatment, other features will likely gain impor tance. For the first time, clinicians have a chance to follow the in vivo response of the tumor exposed to preoperative chemotherapy. The subsequent histological assessment of the tumor sample may likely become an important prognostic guide, permitting more re fined individual approaches to the planning of postoperative adju vant treatment. The value of such a treatment strategy can already be appreciated in the clinical setting, as seen from the therapy of osteosarcoma. Furthermore, preoperative chemotherapy might render previously inoperable tumors operable and hence resectable with a curative intention. The preoperative reduction of tumor bulk may also effectively decrease the need for more radical operations, permitting a more uniform adoption of conservative surgery.

Gastrointestinal Oncology is an evidence-based, practical reference intended to assist in the diagnosis and management of patients with gastrointestinal malignancies. It is designed to be as user friendly as possible and is distinguished by the extremely practical, concrete nature of the information presented and by the multidisciplinary approach adopted. In addition to disease-oriented chapters spanning sites from the esophagus to the anus, non-anatomic subjects such as modern imaging techniques are also addressed. Translational science is supplied where useful in the decision-making process. All of the authors are internationally recognized experts. This book is an ideal resource for oncologists, surgeons, gastroenterologists, and primary-care providers looking for the latest and best information on how to deal with a wide variety of gastrointestinal neoplasms.