Table 4 Adjuvant chemotherapy studies with positive results Study Treatment No. p GITSG 1982 MeCCNU + 5FU 71 Control 71 Neri et al 2001 Epi + 5FU/LV 69 Control 68 Grau et al 1998 MMC 45 MMC + tegafur 40 Hagiwara et al 1992 Kim et al 1992 Cirera et al 1999 IP carbon-absorbed cisplatin Control MMC + 5FU + AraC + OK432 Control MMC + tegafur Control 24 25 74 64 76 72 Abbreviations: FU, ﬂuorouracil; LT, leucovorin; MMC, mitomycin. has also been described as a prognostic factor. In this sense the work by the ITMO group included this parameter in the multivaried analisis (Cox model) proving to be an independ- ent prognostic factor, being the location in middle and distal third better prognosis than in the upper third (p:0.033). Five meta-analyses have been published. The ﬁrst, by Hermans et al (1993), reviewed 11 trials (2000 patients) that compared adjuvant treatments with very uneven therapies, including intraperitoneal chemotherapy, radiotherapy and chemotherapy combined with immunotherapy, with surgery as a control arm. They did not show any survival beneﬁt in the combined arm. The second meta-analysis was presented by Earle and Maroun (1999). They compiled 13 clinical trials, including 1990 patients, and found a small but signiﬁcant survival beneﬁt for patients treated with chemotherapy (odds ratio 0.80, relative risk 0.94). Mari et al (2000) analyzed more than 20 articles taking into account more than 300 patients, and showed an 18% reduction in the risk of death (HR 0.82, p < 0.001). Panzini et al (2002) evaluated more than 3000 patients in a total of 17 clinical trials. Their results showed signiﬁcant survival beneﬁt in patients treated with adjuvant chemotherapy (odds ratio 0.72). Finally Hu et al (2002) reviewed 14 trials involving more than 4500 patients. They found survival beneﬁt in patients treated adjuvantly (odds ratio 0.56). In short, 4 meta-analyses suggest survival beneﬁt, being the most favorable group being that presenting nodular affectation. Another approach to adjuvant treatment of gastric cancer is the perioperative chemotherapy used in the MAGIC trial (Cunningham et al 2006). The study included 503 patients Therapeutics and Clinical Risk Management 2007:3(4) Sup % 30 13 44 67 69 27 45 23 56 36 p <0.03 <0.01 0.004 <0.005 <0.05 0.04 Adjuvant treatment reﬂections Criticism Not reproduced in VASOG y ECOG ? Small number of cases. 11 years conscription. No control group Small number of cases. Australian study negative. Small number of cases. Not reproduced ? with gastric or esophagogastric junction adenocarcinoma in stage II or higher, randomized in to control or to receive three pre-operative cycles and three post-operative cycles of chemotherapy with ECF (epirubicine, cisplatin, and infusional 5FU). The extension of surgery (D1,D2) follows the surgeon’s criteria. Survival at 5 years, although lower than in other studies, shows signiﬁcant difference (p:0.009) favoring the treatment group with 36% in comparison with the 23% of the control group. A fact of great interest in this study is that in the pre-treated group the average of tumor size, the T and the N are signiﬁcantly smaller showing the beneﬁt of pre-operative treatment. Considering this evidence and the lack of a standard, we should consider whether the patient, ie, the ordinary patient outside a clinical trial, should be advised to undergo com- plementary treatment after apparently radical surgery (R0, D1–D2). If the answer is yes, what is the most suitable treat- ment? Is chemotherapy enough? Should we always advise radiochemotherapy? Local relapse and radiotherapy We have already mentioned the importance of local relapse in this neoplasm. This has motivated the inclusion of radiotherapy in the adjuvant treatment of this tumor, in spite of the technical and practical difﬁculties that it entails. The most relevant radiochemotherapy studies are summarised in Table 5. Two of these are not comparative, which limits their value (Park et al 2003; Lim et al 2004). In both, D2 surgery was performed and the patients were treated with 5FU/LV + RT (radiotherapy); they reached a survival of 58% and 60% 565