Treatment of gastric cancer.

Treatment of metastatic and locally advanced gastric cancer and the surgical treatment of cancer in earlier stages, with or without chemotherapy, is discussed in this review. In metastatic disease, the assessment of new chemotherapy protocols is a priority because the tumor is relatively chemosensitive, but results so far have been unsatisfactory. Infusional high-dose 5-fluorouracil (5-FU) appears to be a regimen that could serve as a basis for third generation protocols. The results of surgery in gastric cancer treatment have reached a plateau of effectiveness, and the addition of other treatment modalities is of great interest. In approximately half the cases of locally advanced disease (Tumor 3-4, Node 0-2, Metastasis 0), staged clinically or by laparotomy, a downstaging leading to resectability can be obtained by modern chemotherapy. The long-term survival for these successfully resected patients is approximately 20%. A randomized study comparing surgery alone with the combined treatment modality in clinically staged, locally advanced disease should be undertaken before combined modality treatment will become more generally accepted. In earlier stages of disease, successfully resected, postoperative adjuvant chemotherapy has not proven successful, although a meta-analysis suggested a small benefit. Neoadjuvant chemotherapy has shown to be feasible and should theoretically suppress the malignant cell growth induced by surgery. With the development of more active regimens, (neo-)adjuvant chemotherapy must be further assessed in randomized trials. Intraperitoneal postoperative treatment is another option worth pursuing further.