All authors: New York University, New York, NY.
J Clin Oncol. 2015 Jun 1;33(16):1754-9. doi: 10.1200/JCO.2014.59.7765. Epub 2015 Apr 27.
Despite overall progress in the therapy of local and locally advanced esophageal, gastroesophageal junction, and gastric adenocarcinomas, death as a result of these tumors remains a common outcome. Most randomized phase III trials on which level-one evidence has been built have included the heterogeneous histologies and locations associated with these tumors. However, the different etiologies, molecular biology, and recurrence patterns associated with gastroesophageal malignancies suggest the need to split rather than lump. Biologic and response differences exist between squamous and adenocarcinomas, as well as diffuse and intestinal histologies. This may be a cause behind conflicting outcomes in similar trials. The accepted standard of chemoradiotherapy for locally advanced esophageal and gastroesophageal junction cancers is based on a few positive trials, with the best chemotherapy and total dose of radiation remaining controversial. In the West, the staging evaluations of locally advanced gastric cancer are not uniform. Yet, these evaluations will inform the results of preoperative and perioperative treatments. Although postoperative chemoradiotherapy for gastric cancer has been an accepted treatment option for the last decade, more recent studies have called into question the need for radiotherapy. In perioperative strategies, it has yet to be determined whether histologic or molecular changes in the operative specimen should inform postoperative treatment. An appropriate place for targeted therapy needs to be found in preoperative and postoperative treatment regimens. Finally, because so much is lost when trials are forced to close for lack of accrual, it is imperative to build multidisciplinary consensus before they are launched.
尽管在局部和局部进展期食管、胃食管交界处和胃腺癌的治疗方面取得了总体进展，但这些肿瘤导致的死亡仍然是常见的结果。大多数建立了一级证据的随机 III 期试验都纳入了与这些肿瘤相关的异质组织学和位置。然而，胃食管恶性肿瘤的不同病因、分子生物学和复发模式表明需要细分而不是合并。鳞癌和腺癌以及弥漫型和肠型之间存在生物学和反应差异。这可能是类似试验中结果相互矛盾的原因之一。局部进展期食管和胃食管交界处癌的标准放化疗方案基于少数阳性试验，最佳化疗和总放疗剂量仍存在争议。在西方，局部进展期胃癌的分期评估并不统一。然而，这些评估将为术前和围手术期治疗的结果提供信息。尽管术后放化疗在过去十年中一直是胃癌的一种公认治疗选择，但最近的研究质疑放疗的必要性。在围手术期策略中，仍需要确定手术标本中的组织学或分子变化是否应告知术后治疗。靶向治疗的适当位置需要在术前和术后治疗方案中找到。最后，由于试验因缺乏入组而被迫关闭时会失去很多信息，因此在启动试验之前建立多学科共识至关重要。
