Local Recurrence following Adjuvant Chemotherapy without Radiotherapy in Completely Resected Stomach and Gastroesophageal Junction Adenocarcinoma

Background: The gold standard of adjuvant treatment after surgical resection of adenocarcinoma of the stomach or gastroesophageal junction (GEJ) is chemoradio- therapy. We retrospectively evaluated chemotherapy without radiotherapy in stomach and GEJ adenocarcinoma, using a combination of etoposide, adriamycin and cisplatin (modified EAP). Patients and Methods: Sixty-five patients with completely resected gastric or GEJ adenocarcinoma and positive regional lymph nodes were treated with modified EAP over an 8-year period. Results: Recurrent disease was diagnosed in 38/58 (69% ) patients evaluable for analysis. Only two (5% ) had locoregional recurrence. The main toxicity was hematological, with 22 (34% ) patients developing neutropenic fever and 12 (18% ) anemia requiring blood transfusion. The median survival for the entire group was 20 months, with a median time to recurrence of 11 months. Seventeen (26% ) patients are alive for a median of 7+ years, with no evidence of recurrent disease. Conclusion: Our data cast doubt on the benefit of radiotherapy adjuvant to chemotherapy. The 5-year survival rate for all patients diagnosed with gastric carcinoma remains less than 18% , and reaches only 20-30% , even in those who have undergone resection (1, 2). Because the majority of patients who undergo resection experience relapse and ultimately die of their disease, considerable attention has been paid to neoadjuvant and adjuvant strategies to improve surgical outcome. Meta- analysis of all randomized clinical trials of adjuvant chemotherapy before 2000 revealed a small survival benefit for chemotherapy treatment compared to surgery alone, but with many limitations that do not allow the drawing of a firm conclusion (3). In 2001, the Intergroup-0116 Study (INT-0116), comparing postoperative chemoradiotherapy to observation alone in patients who had undergone potentially curative resection, concluded that this treatment should be considered standard care for all patients at high risk for recurrence, based on improvements in relapse-free survival and overall survival (4). The main benefit of adjuvant therapy in that study was a reduction in the local failure rate rather than preventing the development of distal metastases. The benefit was mainly attributed to the adjuvant radiotherapy which was potentiated by chemotherapy (5).