1. Short-term outcome of neo-adjuvant chemotherapy
for advanced gastric cancer
Chan De-Chuan, Chen Teng-Wei,
Chen Cheng-Jueng, Yu Jyh-Cherng
Division of General surgery
Tri-Service General Hospital

2. Perioperative chemotherapy for locally advanced Gastric Cancer: MAGIC and French trials
Surgery alone
Stage ≥II
Chemoth Surgery Chemoth
MAGIC trial: ECF x 3 => Surgery => ECF x 3 (Total 503 pts)
French trial: FuP x 2 => Surgery => FuP x 4 (Total 224 pts)
increasing the R0 resection rate
improving the overall survival R
Benefits:
New England Journal of Medicine, vol. 355, no. 1, pp. 11–20,2006
Journal of Clinical Oncology, vol. 29, no. 13,pp. 1715–1721, 2011.

3. MAGIC trial

4. FNCLCC FFCD 9703 Trial
Kaplan-Meier curve showing overall survival from date of random assignment.

5. Stage IV gastric cancer is not always a palliative situation (conversion surgery)
Chemotherapy: 60 pt
AIO regimen plus irinotecan
(b) Conversion surgery: 16 pt
Median survival: 24.5m
Median survival: 10.1m
World J Surg (2014) 38:419–425

6. The new the classification of stage IV GC
3-year overall survival rate of 50.1%
Yoshida, Gastric Cancer (2016) 19:329–338
European Journal of Surgical Oncology (2015)41: 1354–1360

7. Materials and Methods From 2014.05 to 2016.12
24 stage IV gastric cancer(liver metastasis, PC or distant LN metastasis) or 5 gastric caner with bulky regional LN (≧ 4cm)
ECOG PS 0-1
1st line chemotherapy regimen: XELOX ± Paclitaxel
Primary end point: response rate
Surgical indication: response to C/T, palliative resection for complication

8. Result: Patient and tumor characteristics
Stage IV(n = 24)
Bulky LN (n = 5)
CRS
(n = 13)
No CRS
(n = 11)
Surgery
(n = 4)
No surgery
(n = 1)
Patient characteristics
Male
Female
Median age 8 4
58 (28-79) 6 5
57(24-68)
66 (63-70) 1 79
Cancer location
Esophagogastric junction
Stomach 3 10
Site of metastasis
Liver
Peritoneum
Peritoneum + other
Distant lymph node
Bulky regional lymph node 9 2
Histology
well
moderatel
moderate-poor
poor 11

9. Result: XELOX-based chemotherapy and response
Stage IV(n = 24)
Bulky LN (n = 5)
CRS
(n = 13)
No CRS
(n = 11)
Surgery
(n = 4)
No surgery
(n = 1)
n(%)
Preoperative chemotherapy
Duration (median, month)
Median cycles
5.4(2.6-11)
8 (3-16)
7.2( )
8 (1-33)
6.4( ) 8
5.4 12
Incomplete C/T(< 6 cycles) 3 4
7(24.1)
Response
Complete
Partial
Stable
Disease progression 1 7 2 6
5(17.2)
13(44.8)
1(3.4)
10(34.5)
HIPEC 11

10. complete response(8); resection; disease free 24.3m
61 y/0 male; cT4aN1M1; liver metastasis (1)
complete response(8); resection; disease free 24.3m
Before
After

11. 61 y/0 male; cT4aN1M1; Liver metastasis (1) Complete response
Before
After

12. 68 Y/O male; cT4aN1M1; liver metastasis (multiple) complete response (10); on resection; disease free 30.6m
After
Before

13. 68 Y/O male; cT4aN1M1; liver metastasis (multiple) Complete response
Before
After

14. 58 Y/O Female; cT4aN1M1; PC(P3) complete response(33), disease free 33
58 Y/O Female; cT4aN1M1; PC(P3) complete response(33), disease free 33.9m
Before
After

15. 53 Y/O female; cT4aN2M1; PC(P3) partial response(12), LTG+ HIPEC; brain meta; alive 18.4m
stomach
colon
Before
After

16. 49 y/o male; cT4aN2M1; distant LN metastasis (Virchow node) partial response(12); LTG; die 18.3m

17. Result: Surgical procedures and outcome
Stage IV(n = 24)
Bulky LN (n = 5)
surgery
(n = 13)
No surgery
(n = 11)
Surgery
(n = 4)
(n = 1)
Surgical procedure
Gastrectomy only
Additional resection of metastasis
CRS + HIPEC 2 9
4 (1HIPEC)
Curability classification
CC0
CC1
CC2 7 4
Mortality 1
Morbidity
Bile leakage
Ileus
Intraabdominal abscess
3(23.1)

18. Result: Follow-up Stage IV(n = 24) Bulky LN (n = 5) CRS (n = 13)
No CRS
(n = 11)
Surgery
(n = 4)
No surgery
(n = 1)
Median FU(months)
12.2
( )
( )
16.3
( ) 11
Median survival from diagnosis
9.5
12.6
1-year OS
1-year PFS
7(53.8)
6(46.2)
6(54.5)
3(27.3)
CRS
No CRS
CRS
No CRS

19. Discussion: compliance
Preoperative C/T was performed more than 6 cycles in % in our series (regimen: XELOX ±Paclitaxel )
Post-gastrectomy C/T was completed in 64% in INT116 trial
Preoperative C/T was completed in 87 % in FNCLCC and FFCD Multicenter Phase III Trial; Post-op C/T in 23% (regimen: CF)
Preoperative C/T was completed in 42 % in MAGIC Phase III Trial; Post-op C/T in 34% (regimen: ECF)

20. Disscussion: response
In our series
17.2% of patients with preoperative C/T showed complete response
41.7% of patients with stage IV gastric cancer with preoperative C/T showed tumor progression but 0% of patients with bulky regional LNs
In resectable gastric cancer , various trials in the preoperative C/T showed pCR from 10% to 20%
15% of patients with locally advanced cancer undergoing preoperative chemotherapy show risks of tumor progression
Journal of the National Cancer Institute, vol. 85, no. 22, pp. 1839–1844, Annals of Surgical Oncology, vol. 14, no. 7, pp. 2010–2017, 2007

21. Disscussion: conversion surgery
Long-term survival seem to be achieved in stage IV gastric cancer patients with CR to C/T
Surgical resection ?

22. Natural history of PC with palliative treatment
- Sadeghi,et al. EVOCAPE 1 (Cancer 2000) : n=125/370 (prospective)
Palliative systemic chemotherapy
Mean and Median survival : 6.5 and 3.1 months
58% of synchronous carcinomatosis
Metastatic gastric cancer with conventional chemotherapy
and targeted therapy (2013)
Median survival: 8 – 18 months
5-year survival: 0%
Gastric cancer 2010, 13:
Lancet oncology 2013,14:

23. 3-year survival rate: 50%.
3-year survival rate: 0%.
In terms of survival benefits, clinically curative surgery resulted in better clinical outcomes

24. Conclusion Advantages of preoperative C/T
Downstage the primary tumor and metastatic lesion
Increase patient compliance to chemotherapy
Conversion surgery for stage IV gastric might be one of the main roles of the surgical oncologist in the near future.