When to consider neoadjuvant (preoperative) therapy in gastric (stomach) cancer?

From the Guidelines

Neoadjuvant therapy should be considered for patients with locally advanced gastric cancer (clinical stage T2 or higher, or node-positive disease) who are candidates for surgical resection, as it can improve R0 resection rates and overall survival, as shown in the most recent guidelines from the European Society for Medical Oncology (ESMO) 1. The standard neoadjuvant regimens include FLOT (fluorouracil, leucovorin, oxaliplatin, and docetaxel), given as 2-3 months pre- and post-operatively, as recommended by the ESMO guidelines 1. Some key points to consider when deciding on neoadjuvant therapy include:

• The patient's clinical stage, with T2 or higher, or node-positive disease being indicative of locally advanced gastric cancer 1
• The potential benefits of neoadjuvant therapy, including improved R0 resection rates and overall survival 1
• The choice of neoadjuvant regimen, with FLOT being a recommended option 1
• The importance of comprehensive staging and regular monitoring during therapy to assess response and manage toxicities 1
• The planning of surgery, typically 4-6 weeks after completion of neoadjuvant therapy, assuming adequate recovery from treatment-related side effects 1 It is also important to note that neoadjuvant chemoradiotherapy may be considered for patients with gastroesophageal junction tumors or those with serosal infiltrating tumors, cancers with bulky nodes, or Bormann type 4 cancers, as shown in the Chinese Society of Clinical Oncology (CSO) guidelines 1. However, the decision to use neoadjuvant therapy should be made on a case-by-case basis, taking into account the individual patient's characteristics and the potential benefits and risks of treatment, as recommended by the Italian Research Group for Gastric Cancer (GIRCG) guidelines 1.

From the Research

Neoadjuvant Therapy in Gastric Cancer

• Neoadjuvant therapy is considered in patients with locally advanced gastric cancer, defined as the primary tumor extending beyond the muscularis propria (cT3-T4) or having nodal metastases (cN+) disease and without distant metastases (cM0) 2.
• The goal of neoadjuvant therapy is to downstage the tumor, making it more resectable, and to address micrometastatic disease 3, 4.
• Various chemotherapy regimens have been studied in the neoadjuvant setting, including ECF (epirubicin, cisplatin, and fluorouracil), EOX (epirubicin, oxaliplatin, and capecitabine), FLOT (fluorouracil, leucovorin, oxaliplatin, and docetaxel), and FOLFOX (fluorouracil, leucovorin, and oxaliplatin) 5, 3, 6, 4.

Indications for Neoadjuvant Therapy

• Patients with resectable locally advanced gastric cancer may benefit from neoadjuvant therapy to improve outcomes 2, 4.
• Neoadjuvant therapy may be considered in patients with proximal cancers, as it has been shown to improve overall survival in this subgroup 4.
• The presence of nodal metastases (cN+) is also an indication for neoadjuvant therapy, as it increases the risk of recurrence and metastasis 2.

Chemotherapy Regimens

• ECF and EOX regimens have been shown to be effective in the neoadjuvant setting, with comparable efficacy and toxicity profiles 5.
• FLOT and FOLFOX regimens have also been studied, with promising results in terms of response rates and overall survival 3, 4.
• The choice of chemotherapy regimen should be individualized based on patient factors, tumor characteristics, and institutional preferences 2, 6.