When do you offer adjuvant radiation in addition to chemotherapy for patients with high risk localized gastric adenocarcinoma who did not receive pre-operative therapy?

The patient went straight to gastrectomy for clinical T1 gastric adenocarcinoma, but post-op was up-graded to T4 disease. Both ARTIST and Intergroup showed better local control, albeit no OS benefit, and RT may have made up for lack of consistent D2 surgery, but this population wasn't specifically studied.

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Radiation Oncology · Emeritus Professor

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Would recommend starting concurrent chemo-radiation 4-6 weeks postoperatively, when the patient has recovered from their surgical procedure.

The US GI Intergroup trial 0116 demonstrated improvement in both RFS and OS for gastric cancer patients at high risk after surgery (T2-4N0, T1-4N+), who were randomized to receive postoperative concurrent chemoradiation when compared with a surgery alone control arm. The above comment that postoperative chemo-radiation in the intergroup trial improved local control but not OS is incorrect. In the US GI intergroup trial, 3-yr RFS with postop chemoRT was 48% vs 31% with surgery alone (p=.001) and 3-yr OS was 50% with CRT vs 41% with surgery alone (p=.005)(Macdonald et al., PMID 11547741). When the analysis was updated with over 10-yr median FU, continued strong benefit from adjuvant postoperative chemoRT was found with regard to both OS (p=0.0046) and RFS (p<0.0001) (Smalley et al., PMID 22585691).