From the Guidelines
Neoadjuvant treatment in resectable gastric cancer is strongly recommended as it offers several important benefits, including improved disease-free survival and overall survival, as demonstrated by the FLOT regimen in the FLOT4-AIO study 1. The benefits of neoadjuvant treatment in resectable gastric cancer can be summarized as follows:
- Tumor downsizing and downstaging, which can increase the likelihood of achieving complete (R0) resection
- Early treatment of micrometastatic disease, potentially eliminating distant metastases before they become clinically evident
- In vivo chemosensitivity test, helping clinicians assess tumor response and adjust postoperative treatment accordingly
- Improved tolerance to preoperative therapy compared to postoperative treatment, as patients' nutritional and performance status is typically better before surgery
- Valuable time for nutritional optimization and smoking cessation before surgery, potentially reducing postoperative complications
- Pathological complete response rates of 15-30% can be achieved with effective neoadjuvant regimens, which correlates with improved survival outcomes The FLOT regimen, which consists of docetaxel combined with oxaliplatin and 5-FU/leucovorin, has been shown to be a effective neoadjuvant chemotherapy regimen for resectable gastric cancer, with a prolonged median disease-free survival and median OS, higher pathological response rate and R0 resection rate, and a more tolerable profile compared to the ECF/ECX regimen 1. It is also important to note that neoadjuvant chemoradiotherapy + surgery + adjuvant chemotherapy has been proven successful in clinical studies of EGJ adenocarcinoma, and the current recommendation for stage III EGJ carcinoma is neoadjuvant chemoradiotherapy followed by radical D2 gastrectomy 1. The efficacy of neoadjuvant therapy should be timely evaluated using recommended imaging modalities, such as EUS, CT, or PET/CT, and explorative laparoscopic staging is recommended prior to prescribing neoadjuvant therapy to improve the diagnostic rates of occult metastasis within the abdominal cavity 1.
From the Research
Benefits of Neoadjuvant Treatment in Resectable Gastric Cancer
- The use of neoadjuvant therapy has been successfully established in patients with curatively resectable disease, and it is now considered a cornerstone in the treatment of gastric cancer and cancer of the esophagogastric junction (EGJ) 2.
- Neoadjuvant chemotherapy has been shown to improve overall survival and disease-free survival in patients with resectable gastric cancer, with a 9% increase in overall survival at 3 years and an 11.6% increase at 5 years 3.
- The benefits of neoadjuvant treatment include improved survival outcomes, increased rates of pathologic complete response, and the potential for downsizing tumors to make them more resectable 4, 5, 6.
- Total neoadjuvant therapy (TNT), which includes both chemotherapy and chemoradiation, has been shown to be associated with promising survival outcomes, with a 5-year overall survival rate of 65.2% and a 5-year disease-specific survival rate of 70.8% 6.
Optimal Neoadjuvant Regimen
- The optimal neoadjuvant regimen for resectable gastric cancer has not been fully established, but combination regimens that include cisplatin and 5-fluorouracil have been shown to be effective 2.
- The EOX (epirubicin, oxaliplatin, and capecitabine) regimen has also been widely accepted as a neoadjuvant treatment option for gastric cancer 2.
- Further research is needed to define the optimal combination regimen and to determine the most effective treatment approach for different patient populations 3, 4, 5.
Patient Selection and Prognostic Indicators
- Patients with locally advanced, marginally resectable gastric cancer with poor prognosis may benefit from neoadjuvant chemotherapy 4.
- Posttreatment pathologic N and M stages have been identified as strong prognostic indicators associated with overall survival and disease-specific survival 6.
- Further research is needed to identify the patients who are most likely to benefit from neoadjuvant treatment and to determine the optimal treatment approach for different patient populations 3, 4, 5, 6.