Preoperative chemoradiation

• Studies have shown that patients who received sequential preoperative induction chemotherapy followed by chemoradiation yielded substantial pathologic responses that results in durable survival time
• Chemoradiation therapy includes radiation therapy of 45-50.4 Gy of external beam with the below preferred preoperative chemotherapy regimens:
  • Paclitaxel & Carboplatin
  • Cisplatin & Fluorouracil
  • Oxaliplatin & Fluorouracil
  • Cisplatin & Capecitabine
  • Oxaliplatin & Capecitabine

• Other preoperative chemotherapy regimens are:
  • Paclitaxel & fluoropyrimidine (Fluorouracil or Capecitabine)

Perioperative chemotherapy

• Widely adopted standard of care throughout most of the UK & Europe
• Composed of 3 cycles preoperative & 3 cycles postoperative:
  • Epirubicin, Cisplatin & Fluorouracil (ECF)
  • Epirubicin, Cisplatin & Fluorouracil (ECF) modifications:
    • Epirubicin, Cisplatin & Capecitabine
    • Epirubicin, Oxaliplatin & Capecitabine
  • Fluorouracil & Cisplatin
• Since Capecitabine avoids the need for an indwelling central venous access & non-inferior to 5-fluorouracil (5-FU) in the advanced disease setting, Epirubicin, Cisplatin & Capecitabine is preferred than Epirubicin, Cisplatin & Fluorouracil regimen
• In patients with operable gastric & lower esophageal adenocarcinomas, perioperative chemotherapy with Epirubicin, Cisplatin & Fluorouracil (ECF) regimen significantly improved progression-free & overall survival rate

Postoperative chemoradiation 

• Preferred treatment in patients who underwent surgery for ≥stage 1B esophagogastric cancer with D0 & D1 lymph node dissection who have not received any preoperative therapy
• For patients with T2, N0 tumors who underwent EMR, observation is recommended
  • Postoperative chemoradiation is only for patients with high risk features (eg poorly differentiated or higher grade cancer, lymphovascular invasion, neural invasion or age <50 years old)
• Fluoropyrimidine (infusional Fluorouracil or Capecitabine) is used before & after fluoropyrimidine-based chemoradiation
• Radiotherapy may be given to a total dose of 45 Gy in 25 fractions of 1.8 Gy, 5 fractions/week by 3D-conformal or intensity-modulated radiation therapy techniques
  • Clinical target volume encompasses the gastric bed (with stomach remnant when present), anastomoses, & draining regional lymph nodes

Postoperative chemotherapy

• Studies have shown that the use of postoperative chemotherapy after curative surgery with D2 lymph node dissection improved disease-free survival compared to surgery alone
• Regimen options include:
  • Capecitabine & Oxaliplatin
  • Capecitabine & Cisplatin
• Capecitabine-Oxaliplatin doublet has been reported to significantly improve overall & disease-free survival