Correspondence

Case 19-2009: Carcinoma of the Gastroesophageal Junction

N Engl J Med 2009; 361:1315-1316September 24, 2009

Article

To the Editor:

In the Case Record of a 63-year-old woman with carcinoma of the gastroesophageal junction, Kwak et al. (June 18 issue)1 provide an excellent overview of the available evidence-based perioperative treatment options, including adjuvant chemoradiation, neoadjuvant chemoradiation, and perioperative chemotherapy. These therapies have never been directly compared and therefore are all reasonable treatment options.2-4 The authors are to be complimented for reaching out in their effort to provide guidance in selecting the optimal treatment approach in particular subgroups of patients (personalized medicine). However, we do not understand why they eventually treated the described patient with both perioperative chemotherapy and additional postoperative chemoradiation. Since no clinical studies support this “double sequential” approach, we would ask the authors to elaborate on why they opted for this particular regimen and did not directly consider postoperative chemoradiation (an approach that is currently being evaluated in a Dutch multicenter trial) if they were so convinced about the disappointing effects of the administered preoperative chemotherapy on the basis of the pathological findings from the surgical specimens.

Hans J. van der Vliet, M.D., Ph.D.
Donald L. van der Peet, M.D., Ph.D.
Henk M.W. Verheul, M.D., Ph.D.
Vrije Universiteit Medical Center, Amsterdam, the Netherlands
jj.vandervliet@vumc.nl

4 References

1. 1

   Case Records of the Massachusetts General Hospital (Case 19-2009). N Engl J Med 2009;360:2656-2664
   Full Text | Web of Science | Medline

2. 2

   Macdonald JS, Smalley SR, Benedetti J, et al. Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med 2001;345:725-730
   Full Text | Web of Science | Medline

3. 3

   Tepper J, Krasna MJ, Niedzwiecki D, et al. Phase III trial of trimodality therapy with cisplatin, fluorouracil, radiotherapy, and surgery compared with surgery alone for esophageal cancer: CALGB 9781. J Clin Oncol 2008;26:1086-1092
   CrossRef | Web of Science | Medline

4. 4

   Cunningham D, Allum WH, Stenning SP, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med 2006;355:11-20
   Full Text | Web of Science | Medline

Author/Editor Response

Van der Vliet and colleagues challenge the “double sequential” approach in which a patient completes the entire preoperative and postoperative components of perioperative chemotherapy, on the basis of the results of the Medical Research Council Adjuvant Gastric Infusional Chemotherapy (MAGIC) study (Current Controlled Trials number, ISRCTN93793971),1 followed by postoperative chemoradiation.2

There is no evidence that the high-risk feature of node positivity after chemotherapy should be used to deviate from completing perioperative chemotherapy. Although the fact that less than 50% of patients in the MAGIC study received all six cycles of chemotherapy suggests that a benefit may be obtained without receiving all doses of chemotherapy, there is no analysis to justify abandoning the perioperative strategy that we initiated in the treatment of our patient.

Furthermore, although node positivity increases the risk of locoregional recurrence, distant metastasis probably remains the dominant pattern of treatment failure.3,4 Thus, we were hesitant to abandon a level 1 recommendation with demonstrated metastatic benefit1 for an approach with no metastatic effect.2,4 The role of chemoradiation remains unclear, in terms of both necessity and timing, and we look forward to the results of the Adjuvant Chemotherapy or Chemoradiotherapy in Resectable Gastric Cancer (CRITICS) study (ClinicalTrials.gov number, NCT00407186) to clarify this issue.

Theodore S. Hong, M.D.
Eunice L. Kwak, M.D., Ph.D.
Massachusetts General Hospital, Boston, MA

4 References

1. 1

   Cunningham D, Allum WH, Stenning SP, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med 2006;355:11-20
   Full Text | Web of Science | Medline

2. 2

   Macdonald JS, Smalley SR, Benedetti J, et al. Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med 2001;345:725-730
   Full Text | Web of Science | Medline

3. 3

   Yoo CH, Noh SH, Shin DW, Choi SH, Min JS. Recurrence following curative resection for gastric carcinoma. Br J Surg 2000;87:236-242
   CrossRef | Web of Science | Medline

4. 4

   Kim S, Lim DH, Lee J, et al. An observational study suggesting clinical benefit for adjuvant postoperative chemoradiation in a population of over 500 cases after gastric resection with D2 nodal dissection for adenocarcinoma of the stomach. Int J Radiat Oncol Biol Phys 2005;63:1279-1285
   CrossRef | Web of Science | Medline