Upfront surgery versus neoadjuvant chemotherapy followed by surgery for resectable advanced gastric cancer. An observational retrospective study.

Introduction Gastric cancer represents a major global health concern, with over 1 million cases diagnosed worldwide each year. Surgical resection remains the only curative option available for gastric cancer and the oncologic outcomes strictly depend on the radicality of surgery. Thus, a multimodal approach involving the combination of preoperative chemotherapy with postoperative adjuvant therapy has been progressively adopted, with the purpose of reducing the lesion size before surgery. Few randomized trials documenting an actual superiority of multimodal approach over upfront surgery alone have been published. However, these studies have a significant underlying bias: the results of the chemotherapy scheme were compared to those of a surgical treatment that was not in conformity with the major international standards in terms of lymphadenectomy and surgical radicality. Aim of the study This retrospective study aims to demonstrate a non-inferiority of up-front surgical treatment (intended as total gastrectomy with D2 lymphadenectomy) alone over current neoadjuvant chemotherapy schemes followed by surgery, in terms of oncological outcomes. Materials and Methods Single high-volume center data of patients with adenocarcinoma of the stomach and of the cardia (Siewert types II and III) submitted either to upfront surgery (SURG group, n=72) or to neoadjuvant chemotherapy plus surgery (NAT group, n=35) were retrospectively analyzed. Results A total of 107 patients with adenocarcinoma of the stomach and of the cardia were included. No statistically significant difference was reported in the overall survival (OS) (80 months for the SURG group and 40 months for the NAT group, p=0.2613) between the SURG and the NAT group. Similarly, disease-free survival (DFS) was comparable between the two groups (10 months for the SURG group, 8 months for the NAT groups, p=0.1629). Patients with cTNM stage III did experience a benefit in terms of OS and DFS when receiving NAT, although the difference did not reach a statistical significance. In 18 patients (51.5%), NAT has led to a significant down staging of the tumor. A R0 resection was reported in 88 patients (82,2%). Conclusion Upfront radical gastrectomy might be considered for patients with early stages of gastric cancer, while neoadjuvant chemotherapy might be an alternative option for patients with resectable locally advanced disease, especially stage III.