Initially unresectable gastric cancer, later resectable after a remarkable response to chemotherapy
Conditions
Interventions
Arm A: Continuation of first-line chemotherapy administered before registration
Arm B: conversion surgery with R0 resection followed by adjuvant chemotherapy with S-1 plus Oxaliplatin (SOX) or Capecit
Sponsors
YOSHIKAWA Takaki
Eligibility
Sex/Gender
All
Inclusion criteria
Inclusion criteria: (1) Histologically proven adenocarcinoma of the stomach. (2) No esophageal invasion or esophageal invasion within 3 cm prior to chemotherapy. (3) Diagnosed as cStage IVB or pStage IV, with fulfillment of any of the following (i) to (iii) regarding distant metastasis before chemotherapy. (i) Unresectable liver metastasis: more than 3 liver metastases on Gd-EOB-enhanced MRI or contrast-enhanced CT. (ii) Unresectable distant lymph node metastasis: distant lymph node metastasis excluding para-aortic lymph node No.16a2/16b1 on enhanced CT. (iii) Unresectable peritoneal dissemination: meeting any of the following (a) to (d). (a) Peritoneal nodules or findings indicative of peritoneal dissemination on enhanced CT, such as ascites beyond the pelvic cavity, hydronephrosis, increased density of peritoneal fat tissue, and thickening of the intestinal wall. (b) Stenosis or deformation of the intestinal wall in the small and large intestine on CT colonography or digestive tract contract inspection. (c) P1b or P1c by laparotomy or laparoscopy (4) One of the following primary chemotherapy regimens is being used: SOX, CapeOX, FOLFOX, SP, XP, or FP. The use of nivolumab or pembrolizumab in the case of HER2-negative patients, the use of zolbetuximab in the case of HER2-negative and CLDN18.2-positive patients, and the use of trastuzumab in the case of HER2-positive patients, and the use of trastuzumab plus pembrolizumab in the case of HER2-positive patients with CPS >- 1, are not restricted. Changes in oral intake status, adverse events, or other reasons may result in a change in regimen to any of the following: SOX, CapeOX, FOLFOX, SP, XP, or FP, or a reduction in the number of drugs. (5) No second- or later-line systemic chemotherapy. (6) No progression of the primary lesion, regional lymph nodes, and distant metastases, and no new distant metastases. (7) Confirmed P0 or resectable P1a by laparoscopy or laparotomy, and CY0 in peritoneal lavage cytology. Intra-abdominal observation and peritoneal lavage cytology are not mandatory in case of following (i) or (ii). (i) T3 or shallower tumor depth before chemotherapy on enhanced CT (no serosal invasion). (ii) T4 or deeper tumor depth before chemotherapy with only liver metastasis. (8) Any of following (i) to (v) are fulfilled before registration in cases that had each distant metastasis before chemotherapy. (i) Liver metastasis: three or fewer resectable liver metastases on Gd-EOB-enhanced MRI confirmed resectable within Makuuchi criteria assessed by ICG test. Even if liver metastasis is diagnosed using contrast-enhanced CT, it should be confirmed using Gd-EOB-enhanced MRI. (ii) Distant lymph node metastasis: all positive metastatic lymph nodes before chemotherapy have decreased to a long axis of less than 6 mm excluding No.16a2/b1 and confirmed resectable. (iii) Ovarian metastasis: judged that curative resection is possible. (iv) Adrenal metastasis: judged that curative resection is possible regarding left adrenal metastasis. Remnant right adrenal metastasis is not allowed. (v) Distant metastasis other than peritoneal dissemination, liver metastasis, distant lymph node metastasis, ovarian metastasis, and adrenal metastasis: disappearance of all distant metastases seen before chemotherapy . (9) Confirmation of meeting all criteria (6) to (8) for distant metastasis within 28 days from the last examination. (10) Conduct of mismatch repair gene function testing. (11) Judged that curative resection is
Exclusion criteria
Exclusion criteria: (1) Synchronous or metachronous (within 5 years) malignancies. (2) Infectious disease requiring systemic treatment. (3) Body temperature of 38 degrees Celsius or higher. (4) Female during pregnancy, within 28 days of postparturition, or during lactation. Males with partners planning conception shortly. (5) Severe psychological disorder difficult to participate in this clinical study. (6) Receiving continuous systemic corticosteroid with a prednisolone equivalent greater than 5 mg/day or immunosuppressant treatment. (7) Under treatment with flucytosine. (8) Unstable angina pectoris, or history of myocardial infarction within 6 months. (9) Uncontrollable valvular heart disease, dilated cardiomyopathy, or hypertrophic cardiomyopathy. (10) Uncontrollable hypertension. (11) Uncontrollable diabetes mellitus. (12) Pulmonary fibrosis or severe pulmonary emphysema based on chest CT.
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Overall survival | — |
Secondary
| Measure | Time frame |
|---|---|
| Event-free survival, progression-free survival, relapse-free survival, pathological response rate, R0 resection rate, chemotherapy continuation rate, chemotherapy dose intensity, adverse events | — |
Contacts
Public ContactEriko SATOMI
National Cancer Center Hospital
Outcome results
None listed