Do you ever give postoperative chemoradiation in patients who underwent preoperative chemotherapy for gastric adencocarcinoma?

This is not a particularly data-driven approach, as the MAGIC trial did not give post-operative chemoradiation (and most patients did not tolerate the planed post-operative chemotherapy), while INT-0116 did not give pre-operative chemotherapy. We don’t have data demonstrating that combining the two trial results, i.e. giving both pre-operative chemotherapy and post-operative chemoradiation is either safe or effective. That said, I have been asked to treat post-operatively when patients are found to have close or positive margins, or other concerning pathologic features after neoadjuvant chemotherapy, and occasionally I have treated in this setting.

This question will be answered by the ongoing Dutch “CRITICS” trial (Chemoradiotherapy after induction chemotherapy of cancer in the stomach), in which patients receive three cycles of ECX prior to surgery, and are then randomized to either post-operative ECX or post-operative radiation with concurrent capecitabine and cisplatin.

Although we lack the data to make this claim, my personal opinion is that the optimal treatment of locally advanced gastric cancer would involve pre-operative chemoradiation, as is the case for GE junction and esophageal cancer. While many phase II trials have been done suggesting this approach is feasible, no randomized trials have been completed. I am hopeful that the ongoing TOPGEAR trial, which compares pre-operative chemotherapy to pre-operative chemoradiation (both arms get post-operative chemotherapy) will be a positive trial, establishing pre-operative chemoradiation as a third valid approach in addition to those of MAGIC and INT 0116.