Treatment of localized gastric cancer.

The curative management of gastric adenocarcinoma depends upon complete resection of the primary tumor. In patients with lymph node metastases in the resected specimen, the relapse and death rates from recurrent cancer are at least 70% to 80%. There is continued debate over whether more extensive lymph node dissection (D2) improves survival when compared to less extensive operations. Until recently, attempts at preventing recurrence have employed adjuvant chemotherapy and have been ineffective. A large US Intergroup study (INT-0116) demonstrated that combined chemoradiation following complete gastric resection improves median time to relapse (30 v 19 months, P <.0001) and overall survival (35 months v 28 months, P =.01). The improvements in disease-free and overall survival created by postoperative chemoradiation have defined a new standard of care. Also the publication of a large phase III neoadjuvant chemotherapy clinical trial using epirubicin, cisplatin, and 5-fluorouracil (5-FU) suggested that this technique may downstage tumors and increase resectability. Future advances in the therapy of resectable gastric cancer may come from studies of preoperative neoadjuvant chemoradiation and the application of targeted therapies such as growth receptor antagonists and antiangiogenesis agents.