The 2nd option is the correct answer. Preoperative treatment increases the likelihood of tumor downsizing/downstaging to better achieve tumor free resection margins, yet only a small percentage of cases are noted to achieve a complete pathologic response (negative for any residual tumor). Difficulty with completing adjuvant chemotherapy or chemoradiation is common in GI malignancies. CRITICS randomized 788 patients to (a) neoadjuvant ECC or EOC chemo (epirubicin, cisplatin/ oxaliplatin, and capecitabine q3wks) × 3 cycles → Surgery → adjuvant ECC or EOC × 3 cycles or (b) preop ECC or EOC × 3 cycles → Surgery → adjuvant chemoradiation to 45 Gy with combined weekly cisplatin and twice/daily capecitabine. Surgery included D2 resection with ≥15 nodes removed. Randomization was stratified by histology and tumor localization. At a median follow-up of 61.4 months, there was no significant difference in the overall survival between the chemotherapy vs. chemoradiation arms. There were similar rates of grade 3 or higher gastrointestinal toxicities between both arms, but grade ≥3 (significant to life threatening) hematologic toxicity rates were worse in the chemotherapy alone arm vs. chemoradiation arm (p = 0.01). Around 50% of patients completed each adjuvant treatment arm in the stated study, which is comparable to other studies investigating adjuvant treatment. Substantial patient dropout, early progression after surgery, treatment toxicity, death, or worsening of general health and patient decline of continued treatment can hamper postoperative treatment. The poor treatment completion rate has led to the CRITICS 2 trial, a phase III trial randomizing patients to chemotherapy vs. concurrent chemoradiation in the neoadjuvant setting, with the hope of improving treatment completion rates and therefore also outcomes.
Twenty months after total gastrectomy, during surveillance follow-up, our patient was identified to have and was treated for B12 deficiency. The outline below is reflective of suggested guidelines for surveillance of patients undergoing total gastrectomy for curative intent, in the non-hereditary setting (NCCN version 1. 2019):
- History & physical q3–6 months x 1–2 years, then 6–12 months × 3–5 years, then annually
- CBC, chemistry profile
- CT chest/abdomen/pelvis with oral and IV contrast every 6-12 months for first 2 years, then annually up to 5 years, and/or can consider PET/CT as clinically indicated
- Monitor and treat as needed for nutritional deficiency (e.g. B12 and iron), especially after total gastrectomy.
- Endoscopy as clinically indicated (for patients with partial or subtotal gastrectomy)