[Complementary treatment to surgery of gastric carcinoma: role of adjuvant and neoadjuvant chemotherapy].

Although there has been a decline in the incidence of gastric cancer worldwide, its mortality rate is still high. In the West, attempts with adjuvant chemotherapy to improve survival have been disappointing. The promising results reported with the FAM (5-FU, Adriamycin, Mitomycin C) regimen in patients with advanced disease, have not been confirmed in an adjuvant setting. Randomized trials on adjuvant chemotherapy in Japan have shown a positive outcome in treated patients only when subgroups with advanced disease are considered. As results with adjuvant chemo-immunotherapy were better than those with chemotherapy alone, immunostimulators have been widely utilized in clinical trials conducted in Japan in recent years. However, chemo-immunotherapy may be more effective in patients with minimal residual disease, due to the combined action of a lower stage at diagnosis and to a diffuse application of standard wide lymphadenectomy. Inadequate lymphadenectomy, like that performed in many western studies, may compromised radicality in patients with "curable" disease and the concept of "minimal residual disease" must therefore be considered in future trials on adjuvant chemotherapy. Future trends for new therapeutic combinations (FAMTX, EAP, 5-FU/Cisplatin, PELF, etc) tested in phase II and III clinical trials are also discussed. Whatever the type of approach used, the high incidence of intra-abdominal recurrences indicates that an improvement in the prognosis of patients with advanced diseases will only come with the development of additional treatment modalities such as neoadjuvant or intraperitoneal chemotherapy.