Mide Kanserinde Neoadjuvan ve Adjuvan Kemoterapi
Özet
Mide kanserinin multimodalite tedavisi; evre, tümör yerleşimi ve hasta performansı gibi faktörlere göre planlanan neoadjuvan ve adjuvan stratejileri içermektedir. Rezektabl lokal ileri hastalıkta, perioperatif FLOT protokolü eski ESF rejimine kıyasla daha üstün genel sağkalım ve daha az toksisite sağlayarak standart yaklaşım haline gelmiştir. Cerrahi sonrasında D2 lenf nodu diseksiyonu yapılan olgularda kapesitabin ve oksaliplatin (XELOX) bazlı postoperatif kemoterapi hastalıksız sağkalımı anlamlı derecede artırırken, D1/D0 diseksiyon yapılan hastalarda postoperatif kemoradyoterapi tercih edilmektedir. Rezeke edilemeyen lokal ileri veya metastatik hastalıklarda ise FOLFOX, XELOX veya FOLFIRI gibi iki ilaçlı birinci basamak rejimler, üçlü kombinasyonlara göre daha iyi tolere edilebilirliği nedeniyle ön plana çıkmaktadır. Hedefe yönelik tedavilerde, HER2-pozitif tümörlerde birinci basamak kemoterapiye trastuzumab eklenmesi sağkalım avantajı sunmaktadır. İkinci ve sonraki basamak tedavilerde ise ramucirumab (tek başına veya paklitaksel ile kombine), MSI-H/dMMR veya PD-L1 pozitif tümörlerde pembrolizumab ve seçilmiş olgularda trifluridin/tipiracil veya NTRK inhibitörleri sağkalım ve semptom kontrolü sağlamaktadır.
The multimodal management of gastric cancer incorporates neoadjuvant and adjuvant strategies tailored to disease stage, tumor location, and patient performance status. In resectable locally advanced disease, the perioperative FLOT regimen has established itself as the standard of care, offering superior overall survival and a more favorable toxicity profile compared to the legacy ECF/ECX protocols. Following surgical resection, post-operative chemotherapy with capecitabine and oxaliplatin (XELOX) significantly enhances disease-free survival in patients undergoing D2 lymph node dissection. Conversely, post-operative chemoradiotherapy remains preferred for patients with incomplete (D0/D1) nodal clearance. For unresectable locally advanced or metastatic disease, two-drug first-line systemic regimens such as FOLFOX, XELOX, or FOLFIRI are favored over triplet combinations due to equivalent efficacy and lower toxicity. Targeted interventions significantly optimize outcomes; adding trastuzumab to first-line chemotherapy provides a clear survival advantage in HER2-positive tumors. In the second-line and subsequent settings, ramucirumab (either as monotherapy or combined with paclitaxel), pembrolizumab for MSI-H/dMMR or PD-L1-expressing tumors, trifluridine/tipiracil, and NTRK inhibitors offer meaningful survival benefits and symptom palliation.
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