Published online Nov 15, 2018. doi: 10.4251/wjgo.v10.i11.398
Peer-review started: July 1, 2018
First decision: July 17, 2018
Revised: September 25, 2018
Accepted: October 7, 2018
Article in press: October 7, 2018
Published online: November 15, 2018
Processing time: 141 Days and 5.2 Hours
Gastric cancer (GC) is the third most common cancer-related cause of death worldwide. In locally advanced tumors, neoadjuvant chemotherapy has recently been introduced in most international Western guidelines. For metastatic and unresectable disease, there is still debate regarding correct management and the role of surgery. The standard approach for stage IV GC is palliative chemotherapy. Over the last decade, an increasing number of M1 patients who responded to palliative regimens of induction chemotherapy have been subsequently undergone surgery with curative intent. The objective of the present review is to analyze the literature regarding this approach, known as “conversion surgery”, which has become one of the most commonly adopted therapeutic options. It is defined as a treatment aiming at an R0 resection after chemotherapy in initially unresectable tumors. The 13 retrospective studies analyzed, with a total of 411 patients treated with conversion therapy, clearly show that even if standardization of unresectable and metastatic criteria, post-chemotherapy resectability evaluation and timing of surgery has not yet been established, an R0 surgery after induction chemotherapy with partial or complete response seems to offer superior survival results than chemotherapy alone. Additional larger sample-size randomized control trials are needed to identify subgroups of well-stratified patients who could benefit from this multimodal approach.
Core tip: Conversion surgery is defined as a surgical treatment with the goal of R0 resection in initially unresectable gastric cancer patients after response to chemotherapy. Although the heterogeneity of metastatic disease factors makes it difficult to identify true prognostic variables, a survival benefit has been demonstrated in several reports. Further prospective large-scale studies seem to be necessary to improve patient selection and to validate this promising multimodal therapy.