Patterns of failure in gastric carcinoma after D2 gastrectomy and chemoradiotherapy: a radiation oncologist's view

Abstract

The risk of locoregional recurrence in resected gastric adenocarcinoma is high, but the benefit of adjuvant treatment remains controversial. In particular, after extended lymph node dissection, the role of radiotherapy is questionable. Since 1995, we started a clinical protocol of adjuvant chemoradiotherapy after D2 gastrectomy and analysed the patterns of failure for 291 patients. Adjuvant chemotherapy consisted of five cycles of fluorouracil and leucovorin, and concurrent radiotherapy was given with 4500 cGy from the second cycle of chemotherapy. With a median follow-up of 48 months, 114 patients (39%) showed any type of failure, and the local and regional failures were seen in 7% (20 out of 291) and 12% (35 out of 291), respectively. When the recurrent site was analysed with respect to the radiation field, in-field recurrence was 16% and represented 35% of all recurrences. Our results suggest that adjuvant chemoradiotherapy has a potential effect on reducing locoregional recurrence. Moreover, low locoregional recurrence rates could give a clue as to which subset of patients could be helped by radiotherapy after D2 gastrectomy. However, in order to draw a conclusion on the role of adjuvant radiotherapy, a randomised study is needed. Gastric cancer is the most common cancer in Korea (Shin et al, 2002). Complete tumour removal with sufficient resection margin plus extended lymph node dissection is considered to be the most important factor in terms of reduced locoregional recurrence and improved survival. Although the incidence of early gastric cancer is increasing, most patients still present with an advanced stage, and, even after complete resection, 38 -94% of patients developed locoregional recurrence (McNeer et al, 1951;Gunderson and Sosin, 1982;Wisbeck et al, 1986;Landry et al, 1990), which translates into 33 -69% of all recurrences (Gunderson and Sosin, 1982;Landry et al, 1990;Maehara et al, 2000;Yoo et al, 2000). However, high recurrence rates may be reduced by adjuvant treatment, so postoperative adjuvant radiotherapy and/or chemotherapy is generally performed.There were several studies (GITSG, 1982;Moertel et al, 1984;Allum et al, 1989;Regine and Mohiuddin, 1992) showing positive effects of radiotherapy and/or chemotherapy in patients with locally advanced or unresectable gastric adenocarcinoma, but the benefit of adjuvant treatment after curative resection remains controversial. Intergroup trial (MacDonald et al, 2001) showed that adjuvant chemoradiotherapy reduced recurrences and increased survival of patients with gastric adenocarcinoma. However, after extended lymph node dissection with R0 gastrectomy, there are no data regarding whether adjuvant radiotherapy could reduce locoregional recurrence and increase survival.The purpose of this study was to analyse the patterns of failure in patients with gastric adenocarcinoma after gastrectomy with D2 lymph node dissection plus postoperative chemoradiotherapy, and to evaluate any effect of adjuvant radiotherapy on locoregional recurrence reduction and su...

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