gms | German Medical Science

Due to the impaired health status of patients after esophagectomy or gastrectomy, adjuvant treatment proved to be difficult to apply in the postoperative phase. In contrast, neoadjuvant (preoperative) therapy is now an integral component of the curative treatment in locally advanced tumors. Only in early cancer (cT1 disease) multimodal treatment is obsolete at present. The discussion whether or not neoadjuvant treatment should be given for cT2 Nx M0 stages is open. For cT3/4 disease there is a clear rationale to give neoadjuvant treatment. In view of the British MRC trial (Lancet 2002) and the “MAGIC” trial (ASCO 2005) there is a robust body of evidence that neoadjuvant chemotherapy leads to an improved overall survival in adenocarcinoma of the upper gastrointestinal tract without any enhancement of postoperative complications or mortality. The difference is about 13% more survivors after 5 years follow-up. Based on current data the treatment should comprise platin and 5-fluorouracil and should last for a minimum of 6 weeks in the preoperative phase. The rationale for radiation/chemoradiation is much less clear at present. Although adjuvant chemoradiation led to a survival benefit in the North American INT 0116 trial including patients with completely resected locally advanced gastric cancer, this therapy led to a considerable morbidity. Moreover, there is a general agreement on the point that adjuvant chemoradiation should be restudied in an adequately resected patient population while tumor resections were not performed according to accepted standards in the North American trial. A new approach in gastric cancer is the application of neoadjuvant chemoradiation. However, this approach is clearly experimental and should be restricted to clinical studies being carried through at highly experienced centers at this stage. Although most studies designed for examining the value of neoadjuvant chemoradiation in esophageal cancer did not show a survival benefit, this treatment is widely used in locally advanced cancers adjacent to the tracheo-bronchial system in order to enhance the chance for complete resectability. These tumors are virtually all squamous cell carcinomas. However, an intense discussion is ongoing which patients with locally advanced squamous cancers are good candidates for surgical resection. Some studies indicate that for some subgroups conservative treatment consisting of chemoradiation alone yields similar results compared to neoadjuvant chemoradiation followed by surgery.