Postoperative adjuvant chemoradiation therapy for patients with resected gastric cancer: intergroup 116.

Abstract

Article Tools SPECIAL DEPARTMENTS Article Tools OPTIONS & TOOLS Export Citation Track Citation Add To Favorites Rights & Permissions COMPANION ARTICLES No companion articles ARTICLE CITATION DOI: 10.1200/JCO.2001.19.6.1879 Journal of Clinical Oncology - published online before print September 21, 2016 PMID: 11251020 Postoperative Adjuvant Chemoradiation Therapy for Patients With Resected Gastric Cancer: Intergroup 116 Roderich E. SchwarzxRoderich E. SchwarzSearch for articles by this author David P. KelsenxDavid P. KelsenSearch for articles by this author Show More City of Hope National Medical Center, Duarte, CAMemorial Sloan-Kettering Cancer Center, New York, NY https://doi.org/10.1200/JCO.2001.19.6.1879 First Page Full Text PDF Figures and Tables © 2001 by American Society of Clinical OncologyjcoJ Clin OncolJournal of Clinical OncologyJCO0732-183X1527-7755American Society of Clinical OncologyResponse15032001In Reply:Dr Schwarz raises the issue of whether the improved outcome seen with chemoradiation therapy as delivered in the investigational arm of Intergroup 116 would be replicated if patients had undergone an adequate lymph node dissection and did not require postoperative radiation therapy. He presents institutional experience suggesting that patients who underwent an extensive retroperitoneal lymph node dissection (D2) had a lower risk of local regional failure than seen in the surgery only control arm of Intergroup 116. On the basis of these data, he recommends a D2 dissection as a standard procedure for patients undergoing potentially curative gastrectomy, limiting the use of postoperative chemoradiation to patients with an R1 dissection, limited numbers of involved lymph nodes, and lesions less than stage T3.As I noted in my discussion, slightly more than half of the patients treated in Intergroup 116 had less than a recommended (D1) lymph node dissection.1 It is possible that the local regional failure rate would have been substantially lower if a D1 or D2 dissection had been performed. However, this is a hypothesis that remains to be proven. The only conclusion we can make from the preliminary data of Intergroup 116 presented to date is that for patients undergoing gastrectomy, postoperative chemoradiation therapy improves 3-year disease-free and overall survival compared with surgery alone. I believe that a strong effort should be made to educate and encourage surgeons who perform gastric cancer operations to at a minimum perform a D1 lymphadenectomy. Although, as Schwarz notes, a D2 dissection has been adopted as a standard approach at several American institutions, two recent large European trials failed to show benefit for the more extensive lymphadenectomy.2,3 We therefore do not have definitive data indicating that, in a multi-institutional study, D2 operations are superior.Second, it may well be that, as has been demonstrated for other malignancies (such as pancreatic cancer), high-volume centers can safely perform an appropriate lymphadenectomy with no increase in operative morbidity and mortality. Referral of newly diagnosed gastric cancer patients who have potentially curative lesions to high-volume centers should also be strongly encouraged.In summary, the role of radiation therapy in preventing local regional recurrence for patients undergoing at least a D1 dissection would be an appropriate question for a future clinical trial. Such a study could be designed in which all patients undergo an R0 resection with at least a D1 lymphadenectomy and are then randomly assigned to receive either chemotherapy as designed in Intergroup 116 or chemoradiation therapy, as in the experimental arm of 116. This would isolate the contribution of external-beam radiation therapy using the dose and schedule utilized in 116 for patients who underwent adequate lymph node dissections.1. Kelsen DP: Postoperative adjuvant chemoradiation therapy for patients with resected gastric cancer: Intergroup 116. J Clin Oncol 18:: 32s,2000-34s, (suppl) Medline, Google Scholar2. Bonekamp JJ, Hermans J, Sasako M, et al: Extended lymph-node dissection for gastric cancer: Dutch Gastric Cancer Group. N Engl J Med 340:: 908,1999-914, Crossref, Medline, Google Scholar3. Cuschieri A, Weeden S, Fiedling J, et al: Patient survival after D1 and D2 resections for gastric cancer: Long-term results of the MRC randomized surgical trial—Surgical Cooperative Group. Br J Cancer 79:: 1522,1999-1530, Crossref, Medline, Google Scholar