LWBK1006-20 LWW-Govindan-Review December 12, 2011 19:4
242 DeVita, Hellman, and Rosenberg’s CANCER: Principles and Practice of Oncology Reviewadvanced stage disease; 85% of patients had node-positive tumors and
69% of patients had T3 or T4 disease. Median overall survival in the
Intergroup 116 study of observation versus postoperative chemoradia-
tion therapy after potentially curative gastrectomy was 27 months in the
surgery alone group and 36 months in the surgery plus chemoradiother-
apy group. The hazard ratio for death in the surgery-alone group was 1.35
(95% confidence interval [CI], 1.09–1.66;p=.005). The Intergroup study
has been criticized for not having good surgical quality control, with only
a minimal number of nodes found in many surgical specimens and with
D2 dissections having been performed in only 10% of patients. How-
ever, commentators often overlook the fact that the Intergroup protocol
was a study of postoperative chemoradiation treatment for patients with
completely resected high-risk gastric cancer; gastrectomy and lymph node
dissection were not part of the protocol treatment because patients were
evaluated for protocol eligibility only after successful recovery following
gastrectomy. As such, the “surgical results” of the Intergroup trial are
best viewed as a reflection of the standard practice of US surgeons and
pathologists.Answer 20.1.16. The answer is A.
The results of the studies and supportive evidence from more recent trials
indicate that fit patients with advanced incurable gastric cancer who can
tolerate potential toxicities have a modest but real benefit in survival com-
pared with best supportive care. The majority of studies that have eval-
uated intraperitoneal therapy for gastric cancer used mitomycin C, and
most trials were performed in Asia. They have all examined intraperi-
toneal therapy in the adjuvant setting after surgery. A meta-analysis of
these studies showed that the majority involved less than 100 patients per
arm. A total of 552 patients had a resection alone, and 609 patients were
randomized to operation plus intraperitoneal treatment. The odds ratio
(OR) was in favor of postoperative intraperitoneal therapy (OR 0.51;
95% CI, 0.4 to 0.65). However, the authors thought that only a few
of the studies were of high quality. They suggested that more rigorously
designed trials with larger numbers of patients and greater power were
necessary before definitive conclusions regarding the effectiveness of post-
operative intraperitoneal treatment could be made. In summary, the use of
intraperitoneal chemotherapy involving either technique is a reasonable
experimental strategy, particularly until more effective systemic agents
can be developed. The goal is improvement in overall survival, as well as
prevention of abdominal carcinomatosis with its associated morbidities,
such as recurrent bowel obstruction.Answer 20.1.17. The answer is A.
Smoking cessation does not appear to decrease the risk of adenocarci-
noma of the esophagus. H. pylori infection, particularly cagA+strains,
is inversely associated with the risk of adenocarcinoma of the esoph-
agus. H. pylori infection can result in chronic atrophic gastritis, lead-
ing to decreased acid production, and potentially reducing the devel-
opment of Barrett’s esophagus. Carcinogenesis in Barrett’s esophagus