Abstract
Simple SummaryGastric cancer (GC) continues to be one of the major oncological challenges on a global scale. The role of neoadjuvant chemotherapy (NAC) in GC is to downstage primary tumour, eliminate potential micrometastases, and increase the chance for radical resection. Although systemic treatment prolongs the survival in advanced GC, persistent lymph node (LN) metastases indicate poor prognosis. Therefore, further identification of prognostic factors after NAC is urgent and could positively influence clinical outcomes. This article aimed to review the actual trends and future perspectives in multimodal therapy of advanced GC, with a particular interest in the post-neoadjuvant pathological nodal stage. Since downstaged and primarily node-negative patients show a similar prognosis, the main target for NAC in advanced GC should be nodal clearance. Adequate staging and personalised perioperative therapy seem to be of great importance in the multimodal treatment of GC.Gastric cancer (GC) continues to be one of the major oncological challenges on a global scale. The role of neoadjuvant chemotherapy (NAC) in GC is to downstage primary tumour, eliminate potential micrometastases, and increase the chance for radical resection. Although systemic treatment prolongs the survival in advanced GC, persistent lymph node (LN) metastases indicate poor prognosis. Further identification of prognostic factors after NAC is urgent and could positively influence clinical outcomes. This article aimed to review the actual trends and future perspectives in multimodal therapy of advanced GC, with a particular interest in the post-neoadjuvant pathological nodal stage. A favourable prognostic impact for ypN0 patients is observed, either due to truly negative LN before the start of therapy or because preoperative therapy achieved a pathologically complete nodal response. Ongoing trials investigating the extent of lymphadenectomy after neoadjuvant therapy will standardise the LN dissection from the multimodal therapy perspective. Since downstaged and primarily node-negative patients show a similar prognosis, the main target for NAC in advanced GC should be nodal clearance. Adequate staging and personalised perioperative therapy seem to be of great importance in the multimodal treatment of GC.
Highlights
An effective manner to distinguish those two processes is fine-needle aspiration (FNA) for cytological assessment, which should be performed unless the primary tumour and large vessels are in close proximity [10]
Magnetic Resonance Imaging (MRI) is currently not recommended for nodal assessment [10]
Since no firm conclusions can be made on solely performing FDGPET/Computed tomography (CT) [46], the results of the PLASTIC study should be awaited [47], which hypothesized that performing PET and staging laparoscopy(SL) for locally advanced Gastric cancer (GC) results in a change of treatment strategy in 27% of patients
Summary
A 5-years OS in advanced GC patients treated with optimal multimodal therapy, based on systemic chemotherapy and surgery does not exceed 38%, as shown in FNCLCC and FFCD Multicenter Phase III Trial [4]. The role of neoadjuvant chemotherapy (NAC) in nodal metastasis remains unknown and constituted the aim of JCOG trials [5,6]. Post-neoadjuvant pathological stage (yp) is considered as important survival predictor [14]. It allowed distinguishing several groups of patients by nodal involvement: cN0/ypN0 (node-negative), cN+/ypN0 (downstaged N0) and ypN+ (node-positive). This article aimed to review the actual trends and future perspectives in multimodal therapy of advanced GC, with particular interest on post-neoadjuvant pathological nodal stage
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