Is neoadjuvant chemotherapy prior to radio-chemotherapy beneficial in T4 anal carcinoma?

BACKGROUND: This study retrospectively describes the outcome of a series of 38 patients (pts) with T4 anal carcinoma exclusively treated by radio and chemotherapy. PATIENTS AND METHODS: From 1992 to 2007, 38 pts with UST4-N0-2-M0 anal carcinoma were treated with exclusive radiotherapy and chemotherapy. All patients received external beam radiotherapy (EBRT) (median dose 45 Gy) with a concomitant chemotherapy (5-fluorouracil-cisplatin). Eleven patients received neo-adjuvant chemotherapy (5-fluorouracil-cisplatin). After 2-8 weeks, a 15-20 Gy boost was delivered either with EBRT (20 pts) or interstitial (192)Ir brachytherapy (18 pts). Mean follow-up was 66 months. RESULTS: After chemoradiation therapy (CRT), 13 pts (34%) had a complete response, 23 pts (60%) a response >50% (2 pts were not evaluated). The 5-year-disease-free survival was 79.2 ± 6.5%, and the 5-year overall survival was 83.9 ± 6%. Eight patients developed tumor progression (mean delay 8.8 months), six of them requiring a salvage surgery with definitive colostomy for local relapse. Late severe complication requiring colostomy was observed in 2 pts. The 5-year-colostomy-free survival was 78 ± 6.9%. Patients who received primary chemotherapy had a statistically significant better 5-year colostomy-free survival (100% vs. 38 ± 16.4%, P = 0.0006). CONCLUSION: T4 anal carcinoma can be treated with a curative intent using a sphincter-sparing approach of CRT, and neo-adjuvant chemotherapy should be considered prior to radiotherapy.

Results of a phase I-II study on intraductal confocal microscopy (IDCM) in patients with common bile duct (CBD) stenosis.

BACKGROUND: Confocal endomicroscopy is an emergent technique and allows real optical biopsies in the gastrointestinal (GI) tract. The aim of this study was to evaluate a new intraductal confocal miniprobe in patients with a normal common bile duct (CBD) or with a suspicion of a malignant stenosis (cholangiocarcinoma). METHODS: Thirty-seven patients (23 males) underwent endoscopic retrograde cholangiopancreatography (ERCP) for bile duct stone removal (7 cases) or bile duct stenosis (30 cases). Intraductal confocal microscopy (IDCM) was performed during the ERCP using a probe-based confocal laser endomicroscopy (pCLE) technique. IDCM was done with the CholangioFlex probe with Cellvizio (Mauna Kea Technologies, Paris, France). The depth of penetration of theCholangioFlex probe was 40-70 µm and magnification was 400×. Images were reviewed by an experienced pathologist in GI disease and compared to ERCP findings, CBD biopsies performed during ERCP or EUS, and in 15 patients to the resected specimen (Wipple resection). RESULTS: No complications related to the CholangioFlex insertion occurred after the ERCP. Good images were obtained in 33 patients. Final histology diagnosis was a normal CBD in 7 cases, 23 malignant stenoses (4 ampullary carcinomas, 13 cholangiocarcinomas, and 6 pancreatic cancer), and 7 inflammatory stenoses (4 chronic pancreatitis, 1 stenosis of hepaticojejunal anastomosis, 1 postcholecystectomy CBD stenosis, and 1 primary sclerosing cholangitis). IDCM of a normal CBD showed a thin black band (<20 µm), normal vessels (thin and regular), and no visible glands. IDCM of malignant strictures revealed irregular vessels with lack of contrast in the CBD wall, large black band (>20 µm), and an aggregate of irregular black cells (black clumps). These aspects were seen in all malignant stenoses and none were seen in benign or normal CBD. The presence of irregular vessels, large black bands, and black clumps seen with confocal laser microscopy enabled prediction of neoplasia with an accuracy rate of 86%, sensitivity of 83%, and specificity of 75%. The respective numbers for standard histopathology were 53, 65, and 53%. CONCLUSION: This phase I-II study on IDCM showed that IDCM is feasible. This new technique will open a new door for optical biopsy of the CBD.

Circumferential endoscopic resection of Barrett's esophagus with high-grade dysplasia or early adenocarcinoma.

BACKGROUND: Barrett's esophagus-related high-grade dysplasia or mucosal cancer can be treated by endoscopic mucosal resection (EMR), but the adjacent metaplastic epithelium remains at risk for developing further lesions. Our objective was to evaluate the results of the circumferential EMR in removing not only the neoplastic lesion but also the remaining Barrett's epithelium. METHODS: Forty-one consecutive patients (mean age: 66 years) with Barrett's esophagus were submitted to 63 EMR sessions in one single-referral endoscopic unit. All patients had high-grade dysplasia, and cancer was detected in 23 of these cases, most of them classified as T1N0 (20 patients) by endosonography. Mucosectomy after saline submucosal injection was performed for the neoplastic lesions and, if necessary, the residual Barrett's epithelium was removed by the same technique one month later. RESULTS: A retrospective evaluation showed that, during a mean follow-up of 31.6 months, Barrett's epithelium was completely replaced by squamous epithelium in 31 (75.6%) cases. There were 10 complications, all of which were managed endoscopically: 8 cases of bleeding and two perforations occurred in 9 (14.3%) patients. One patient developed an esophageal stricture. Barrett's epithelium recurred in 10 (24.4%) patients and recurrent or metachronous early cancer was detected in 5 (12.2%), all but one of which were treated again by EMR; the fifth patient was referred to surgery. Argon plasma coagulation was used in 6 cases to treat Barrett's epithelium, and two patients received concomitant chemoradiotherapy as adjuvant therapy. CONCLUSIONS: Circumferential EMR provides an effective endoscopic approach to the management of Barrett's esophagus-related high-grade dysplasia and mucosal cancer. Additional studies are necessary to evaluate the long-term results.

Concerted nonsyntenic allelic losses in hyperploid hepatocellular carcinoma as determined by a high-resolution allelotype.

Although the occurrence of loss of genetic material in hepatocellular carcinoma (HCC) has been documented both by cytogenetic analysis and by monitoring of allelic losses, a global overview of the extent and frequency of deletion occurring throughout the genome is not yet available. To contribute to this information, DNAs extracted from flow-sorted aneuploid nuclei from HCC and matched normal DNAs were typed for 275 microsatellite loci that were distributed along the autosomes. An average of 190 (69%) informative loci per case were generated on 48 HCC. Complete loss of heterozygozity in the tumor DNA was observed for 15.6% of the typed loci. The chromosome segments that were most frequently affected by deletion were: 8p (60%), 17p (48%), 1p (44%), 4q (42%), 16p (40%), 16q (39%), 6q (35%), 9p (30%), and 13q (29%). On average, 8 of the 39 chromosome segments studied per tumor carried at least one locus that demonstrated loss of heterozygosity (ie., the fractional allelic loss was 0.21). Groups of concerted nonsyntenic losses were observed for 16p and 1p and for 16p and 4q. The location of putative tumor suppressor genes on the most frequently deleted regions was confirmed and, in some cases, refined.

The oncological safety of laparoscopic total mesorectal excision with sphincter preservation for rectal carcinoma.

BACKGROUND: Although experience of laparoscopic treatment of rectal carcinoma has been reported, there is no evidence of its oncological safety because most procedures included partial mesorectal excision or abdominoperineal excision and quality of surgery is lacking. The aim of this study was to assess the oncological results of laparoscopic total mesorectal excision with sphincter preservation for rectal carcinoma. METHODS: From 2000 to 2003, 144 patients underwent laparoscopic total mesorectal excision with low colorectal or coloanal anastomosis for mid and low rectal adenocarcinoma. There were 88 men and 56 women, with a median age of 65 years. The tumor was located at 5.5 cm (range 1-12) from the anal verge and was classified uT1T2 in 25 cases and uT3 in 119 cases. One hundred twenty patients received preoperative radiotherapy. RESULTS: Postoperative mortality and morbidity were 1% and 34% respectively. Conversion was 14% (n = 20). Macroscopic assessment of the specimen (n = 92) showed an intact mesorectum in 88% of the cases. The distal margin and the circumferential margin were safe in 98% and 94% of the cases, respectively. A complete microscopic excision, i.e., R0 resection, was achieved in 134 cases (93%). Pathological data were similar to those of an open match group. With a median follow-up of 18 months, there was no port-site recurrence and two patients had local recurrence (1.4%). The 3-year overall and disease- free survival rates were 89% and 77%, respectively. CONCLUSIONS: A high quality of surgical excision can be achieved by the laparoscopic dissection, suggesting that this approach in treatment of rectal carcinoma is oncologically safe.

Increased expression of the mRNA encoding the somatostatin receptor subtype five in human colorectal adenocarcinoma.

Numerous studies have suggested that the antiproliferative potency of somatostatin (SS) analogues may be an efficient tool to improve the prognosis of colorectal cancer. In order to facilitate current efforts to design potent antitumour SS analogues, we studied the distribution of human SS receptors (hsst1-5) mRNAs in a large set of tumoural and normal colonic tissues. Localisation of hsst1-5 mRNAs in normal and tumoural tissues was performed by in situ hybridisation using radioactive antisense or sense riboprobes. Semi-quantitative analysis of hsst5 mRNA was performed using a computerised image analysis system. Hsst binding sites were characterised by studying the relative potency of SS14, SS28 or SS analogues in displacing [(125)I]Tyr degrees -d-Trp(8)-SS14 bound to HT29-D4 cells. Hsst5 mRNA was by far the most expressed subtype in both normal and transformed epithelial cells as well as in the HT29-D4 cell line. An increased expression of hsst5 mRNA was found in tumours. Hsst1 mRNA was expressed preferentially as clusters in immune cells in lamina propria and in stroma close to the tumour. A low expression of hsst4, hsst3 and hsst2 was seen in normal and tumoural tissue. In HT29-D4, binding experiments with SS14 demonstrated the existence of one SS binding class (K(d)=524 nM, B(max)=1fmol/10(6 )cells). In competition binding studies, SS28 and BIM23268 (an analogue that shows preferential specificity towards hsst5) effectively inhibited binding of [(125)I]Tyr degrees -d-Trp(8)-SS14 (IC(50)=15 and 157 nM respectively), while BIM23197 (an analogue that shows preferential affinity for hsst2) was ineffective. Our results show a high expression of hsst5 mRNA in human tumoural colonic tissue, while hsst5 protein is the predominant hsst protein subtype in a tumoural colonic cell line.

Detection of gastrin mRNA in fresh human colonic carcinomas by reverse transcription-polymerase chain reaction.

To investigate the hypothesis that gastrin might be synthesized by tumour tissues in cancer of the colon, samples from six human colon tumours, one hepatic metastasis, four normal colonic mucosal samples and two antral and one fundic gastric mucosal samples from nine patients were analysed to determine whether gastrin mRNA was present. RNA was extracted from surgical specimens by ultracentrifugation on a CsCl cushion, purified using the guanidinium thiocyanate method, reverse-transcribed and amplified by polymerase chain reaction. Gastrin mRNA was detected in each colonic carcinoma sample (including the hepatic metastasis), while no such signal was observed in normal colon biopsies. Positive and negative controls (gastric antrum and fundus respectively) gave the expected results. In each of the positive samples, the chemiluminescent revelation of amplified products after Southern blotting corresponded to gastrin mRNA without the intron. These findings demonstrate the ability of primary and metastatic human colonic tumours to produce gastrin mRNA. Since malignant cell lines have been reported to produce gastrin peptide, and since gastrin receptors were present in some cases, our results support the idea that gastrin may be involved in an autocrine mechanism.

MSH2 and MLH1 immunodetection and the prognosis of colon cancer.

MSH2 and MLH1 are proteins involved in DNA reparation. They are mutated in some forms of colon cancer, i.e. hereditary non-polyposis carcinomas and a subset of sporadic carcinomas. We have studied the expression of MSH2 and MLH1 in a retrospective series of 225 colorectal carcinomas by immunohistochemistry. The results were compared to molecular tests of microsatellite instability using amplification by PCR of BAT-25 and BAT-26 repeated sequences and to histoclinical data. Positivity of both proteins was never associated with MSI phenotype. MSH2 and/or MLH1 negative tumors were frequently tumors of the proximal colon; in this subpopulation or proximal tumors, MSH2 and/or MLH1 negativity was associated with a longer disease-free survival.

No loss of sst receptors gene expression in advanced stages of colorectal cancer.

As demonstrated by several studies, the pan-inhibitory peptide somatostatin (SS) is implicated in a large variety of physiological processes in the gastrointestinal tractus. SS inhibits hormonal and gastric acid secretions, and decreases gastric and intestinal motility, mesenteric blood flow and intestinal absorption. In vitro and in vivo studies showed also that the antiproliferative potency of SS analogs may be a target to improve the prognosis of colorectal cancer. Here we report the expression profile of the five SS receptor subtypes (hsst1-5) mRNAs in a large set of tumoral and normal colon. Using reverse transcription-PCR, we showed that hsst5, hsst1 and hsst2 mRNA subtypes were the most frequently expressed hsst mRNA subtypes in normal and pathological colon. Interestingly, we found that the frequency of hsst5 mRNA expression in the left colon was significantly higher in tumors than in normal samples: 81. 2% (13/16) and 36.4% (4/11) respectively (0.025>P>0.01, chi2 test with Yates' correction). We did not find any influence of Dukes' stage on hsst mRNAs expression. Of interest, no loss of hsst2 and hsst5 mRNA expression in advanced stages was noted. Some differences in the frequency of expression of hsst mRNAs according to the origin of the tissue (left or right colon) were evident. The expression of hsst5 and hsst2 mRNA in advanced colorectal carcinoma associated with the development of new SS analogs boost the relevance of colorectal cancer treatment by somatostatin analogs.

Ultrastructural study of osteosarcomas.

The ultrastructural examination of four osteosarcomas (osteogenic, undifferentiated, and pleomorphic) is described. There are three types of tumor cells. Most of the cells are held in contact by desmosome-like tight junctions; they are atypical osteoblasts with cytoplasmic processes, dilated rough endoplasmic reticulum, mitochondria carrying calcific inclusions, lipid droplets surrounded by glycogen, and intracellular fine filamentous fibers. Other cells exhibiting varying degrees of osteoblastic maturity are also seen with multilobed nuclei, a clear cytoplasm, and straight bordered membranes. The last type is chondroid with abundant deposits of glycogen, lipid droplets, and undilated rough endoplasmic reticulum. The matrix is composed of fibrils without periodicity, scattered and deteriorated collagen fibers, and focal calcium deposits of hydroxyapatite crystals as in embryonal bone, dentine, or callus bone.

Detection of gastrin mRNA by in situ hybridization using radioactive- and digoxigenin-labelled probes: a comparative study.

The hormone gastrin is mainly produced by the G cells of the antral mucosa and plays a major role in the regulation of digestive mucosal growth. Since it permits identification of cell types containing mRNA, in situ hybridization (ISH) appears to be an interesting method for studying gastrin-producing tissues. In this study, in situ detection of gastrin mRNA has been carried out on frozen sections of four human normal antral mucosa samples and of six colonic carcinomas removed from patients with high levels of plasma gastrin, using a gastrin oligonucleotidic DNA probe. We have compared the results provided respectively by the [35s] labelling and the digoxigenin labelling of the synthetic probe. Positive cells were found in each normal sample analysed with radioactive- as well as digoxigenin-labelled antisense probes. The total number of cells expressing gastrin mRNA appeared slightly higher with the [35s]-labelled probe, while the digoxigenin-labelled probe gave a better definition of positive signals. In contrast, neither radioactive nor cold probes gave positive signals in the six colonic carcinoma samples, although gastrin expression had been demonstrated in these tumours using a reverse transcriptase-PCR method. These results show that, although ISH does not seem sensitive enough to allow the detection of very low levels of gastrin expression, it would appear to be a reliable method for visualizing gastrin mRNA in human antral mucosa.

Detection of gastrin mRNA in paraffin-embedded samples of normal antral mucosae using polymerase chain reaction technique.

Gastrin, a peptide hormone produced by the G cells of the gastric antrum, plays a major role in the regulation of digestive mucosal growth. Although some light has been shed on the peptidic aspects of this hormone's mode of action and the co-regulatory activity in which it is involved along with the other gastrointestinal hormones, little is known at present about the modes of expression of its mRNA at the tissue level. A few attempts have been made so far to detect the transcript, mostly using molecular hybridization techniques. Here it was proposed to detect gastrin mRNA using a RT-PCR technique on a series of paraffin-embedded samples of normal human antrum processed with various fixatives commonly used in histology. The transcript was detectable in all the 7-microns sections of the samples treated with either formalin or Carnoy's solution, whereas Bouin's solution, which is also used as a fixative in histology, was found to have inhibitory effects on the method described here.

Differential MUC 1 expression in normal and neoplastic human pancreatic tissue. An immunohistochemical study of 60 samples.

Neoplastic transformation of epithelial cell sis commonly associated with altered synthesis of mucin glycoproteins. Few studies have been performed on the correlation between MUC 1 expression and pancreatic carcinoma using immunohistochemical methods. We compared the patterns of MUC 1 expression in normal pancreatic tissue, in pancreatic carcinoma, and in chronic pancreatitis. Immunohistochemical studies were performed using 3 monoclonal anti-MUC 1 antibodies (12C10, 1G5, and H23) on surgical specimens and on fine-needle aspiration biopsy specimens. In the neoplastic cells from adenocarcinomas, high levels of cytoplasmic MUC 1 expression were observed, with some membrane staining. No such cytoplasmic expression was observed in normal tissue, tissue from chronic pancreatitis, or benign neoplastic tissue. These data show conspicuous quantitative and qualitative differences between the patterns of MUC 1 expression observed in nonmalignant vs malignant pancreatic tissue and may be useful in the histologic diagnosis of adenocarcinoma in biopsy samples.

Detection of telomerase in hepatocellular carcinomas using a PCR ELISA assay: comparison with hTR expression.

BACKGROUND: While telomerase is undetectable in most normal somatic tissues, telomerase activation has been detected in many immortal cell lines and various cancers. AIM: To investigate telomerase expression in hepatocellular carcinoma, and to assess the expression of the RNA component of telomerase, hTR. METHODS: 39 hepatocellular carcinomas were studied using a telomerase polymerase chain reaction (PCR) enzyme linked immunosorbent assay, which does not require radioactive PCR amplification and yields a semiquantitative measurement. Expression of hTR was also assessed by a non-radioactive in situ hybridisation procedure. The correlations between these two markers and the clinicopathological data were analysed. RESULTS: Telomerase activity was detected in 23 of 39 hepatocellular carcinoma specimens (59%). Comparison of hepatocellular carcinoma with and without telomerase expression, or with high and low telomerase (10 cases v 13 cases), showed no differences in the principal clinicopathological data. Although median survival was lower in the group with detectable telomerase activity than in that with undetectable activity (510 v 720 days) the difference was not significant (log-rank test, p = 0.08). hTR expression was detected in 11 of 14 cases of hepatocellular carcinoma tested (78%) and in four of 12 samples of adjacent non-cancerous tissue (33%). Five tumours and four non-cancerous tissues were positive for hTR, whereas no telomerase activity was detected in these. CONCLUSIONS: The presence of telomerase activity in hepatocellular carcinomas is confirmed. No correlation was observed between clinicopathological data and telomerase expression in hepatocellular carcinoma, but survival seemed better in the absence of telomerase expression. hTR seems to be more widely expressed than telomerase.

Gastric duplication in an adult mimicking mucinous cystadenoma of the pancreas.

Gastric duplication cyst (GDC) in an adult can have several clinical presentations. A review of the literature showed previously reported cases of GDC presenting as pancreatic pseudocyst or with greatly raised concentrations of carbohydrate antigen 19-9 (CA 19-9). It is often difficult to discriminate GDC from pancreatic cystic tumour, in particular pancreatic mucinous cystadenoma, in which concentrations of carcinoembryonic antigen and CA 19-9 are classically raised. This report describes an adult case of GDC mimicking a mucinous cystadenoma of the pancreas. This is the first report of a simultaneous increase in carcinoembryonic antigen and CA 19-9 in GDC in the absence of malignancy. Although few cases of carcinoma arising from a GDC having been reported, the production of oncofetal antigens raises the problem of a precancerous condition in long standing intestinal duplications. In this situation surgical resection must be performed.

A phase II single institutional experience with preoperative radiochemotherapy in pancreatic adenocarcinoma.

BACKGROUND: Resection of pancreatic adenocarcinoma has a limited impact on survival. We hypothesized that delivering preoperative radiochemotherapy (RTCT) might enhance local control of the cancer and improve survival. METHODS: Nineteen patients with localized pancreatic cancer (14 head and 5 body) were treated during the past 4 years with an intramural protocol consisting of continuous infusion of fluorouracile (5-FU: 650 mg/m(2)/D1-D5 and D21-D25 and Cisplatin 80 mg/m(2)/bolus D2 and D22 with preoperative external beam radiotherapy (RT) (30Gy split course RT or 45 Gy standard fractionation RT). RESULTS: Four patients did not have surgical resection: Three patients were noted to have liver metastases and 1 patient developed peritoneal carcinomatosis. The remaining 15 patients had potentially curative resection (12 Whipple procedure and 3 distal subtotal pancreatectomy). There was no postoperative death. Pathologic findings showed five major responses including 2 patients with complete pathologic response. The overall median survival for the 19 study patients was 20 months. The median disease free and 2-year overall survival for the group with resection were 30 months and 52.3%. CONCLUSIONS: Preoperative RTCT followed by resection is well-tolerated and safe for patients with localized pancreatic cancer. Major histological response occurred for 25% of patients. This approach could offer improvement in patient survival.

The human gastrin/cholecystokinin receptors: type B and type C expression in colonic tumors and cell lines.

The CCK-type B receptors are recognized by gastrin, which is known to be possibly involved in the development of gastro-intestinal cancers; alternate splicing of exon 4 of the human CCK-B receptor gene gives 2 different mRNA isoforms, the exact significance of which still remains to be elucidated. The recently described CCK-type C receptors recognize gastrin but do not discriminate between mature and immature forms of the hormone. A series of healthy and tumoral colon samples, the associated hepatic metastases and four colonic cell lines were examined for gene expression of the 2 isoforms of the CCK-B receptor and the CCK-C receptor using reverse transcription-polymerase chain reaction. Gastrin mRNA expression was also investigated. The short isoform of the CCK-B was detected in 80% of the normal colon tissues, 76.5% of the colon tumors, 100% of the metastasis samples and 75% of the colonic cell lines; whereas the long isoform, which is presumably more strongly activated by gastrin, was expressed in 50% of the normal colon samples, 23% of the colon tumors, 43% of the hepatic metastases and 1 cell line (Sk-Co15). However, although CCK-C transcript was detected in 100% of the tumors tested and gastrin mRNA in 86.5%, only 16.5% also expressed the long isoform of the CCK-B receptor. The gastrin/CCK-B receptor might therefore be involved in an hypothetic autocrine proliferative loop only in some colonic tumors, and the receptor mainly involved in this loop may well be the CCK-C receptor, since its mRNA is expressed as often as gastrin mRNA in tumors and cell lines.

[Adenocarcinomas of the distal esophagus. Adenocarcinomas of the cardia]. / Adénocarcinomes du bas oesophage. Adénocarcinomes du cardia.

Adenocarcinomas of the distal esophagus and the gastric cardia have many similar characteristics and common risk factors. Gastric cardia tumors are more closely related to esophageal adenocarcinomas than to distal gastric carcinomas. Adenocarcinomas of the distal esophagus and gastric cardia should be regarded as one clinical entity. However the two types of tumor differed in prevalence of molecular characteristics that are interesting to analyze, to identify the risk factors specially associated with each entities.

[Clinical practice guidelines: 2004 Standards, Options and Recommendations for the management of patient with adenocarcinoma of the stomach--radiotherapy]. / Recommandations pour la pratique clinique : standards, options et recommandations 2004 pour la prise en charge par radiothérapie des patients atteints d'adénocarcinomes de l'estomac (cancers du cardia, autres types histologiques exclus).

CONTEXT: "The Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the Federation of French Cancer Centers (FNCLCC), the 20 French regional cancer centers, and specialists from French Public Universities, General Hospitals and Private Clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and the outcome of cancer patients. OBJECTIVES: To elaborate clinical practice guidelines for patients with stomach adenocarcinoma. These recommendations cover the diagnosis, treatment and follow-up of these tumors. METHODS: The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery. The Standards, Options and Recommendations are thus based on the best available evidence and expert agreement. RESULTS: Adjuvant radiation therapy alone is not a standard treatment for patients with stomach adenocarcinoma. Adjuvant concomitant chemoradiotherapy is not a standard treatment for patients with stage II or III stomach adenocarcinoma R0, with Dl or D2 lymphadenectomy who have undergone surgery. Following surgical resection, adjuvant concomitant chemoradiotherapy should be proposed to patients without denutrition with a lymphadenectomy < Dl (fewer than 15 lymph nodes examined) and those with T3 and/or N+ tumours following the protocol used in the MacDonald trials (SWOG-9008) (Level of evidence B1). Adjuvant concomitant chemoradiotherapy can be administered to patients without denutrition with DI or D2 lymphadenectomy and with involvement of regional lymph nodes (N2 or N3).