Repetitive transarterial chemoembolization (TACE) of liver metastases from gastric cancer: Local control and survival results: Will there be clinical implications in the future ?

The authors reported attractive results, achieved by trans-arterial chemoembolization (TACE) management of patients affected by liver metastases from gastric cancer (GC). Although their survival data derived from a retrospective analysis, we think interesting to stress their potential clinical relevance. Therefore, we would like to make a general discussion and finally address some issues regarding their data. Despite a declining incidence in many developed Countries GC remains a frequent, highly lethal neoplasm. Despite new schedules and drugs combinations, only little progresses have been made, anyhow some recent results are encouraging. The most important advance in the last year came from the “ToGA” study, an open-label international phase 3 randomized controlled trial, undertaken in 122 centers in 24 Countries, were the addition of monoclonal antibody trastuzumab to a cis-platin and capecitabine combination chemotherapy was compared to cisplatin and capecitabine chemotherapy alone, in a population of Her2 positive metastatic EG patients. Considering that this patient population is often unfit to receive further medical treatments, there is debate on the utility of a second-line chemotherapy. Most clinicians think reasonable that patients should be managed on an individual basis and deserve a comprehensive explanation balancing any potential risks with benefits, with particular attention to quality of life. Recently two randomized phase III trial showed survival benefit of second line chemotherapy vs. best supportive care. We remark that the decline in the performance status of the patients more often caused by the presence of bulky or multi-site diffusion of cancer, that cannot be managed with local treatment modalities only, rather than from lack of control of liver-confined disease. Furthermore we did not find in the paper any description either of patients or of disease characteristics; therefore, we do not have enough information available to understand if the amazing survival results reported were explicable by clinical factors rather than by the choice of treatment. Finally, we do not agree with the choice of Gemcitabine because it is not an effective drug in GC. At moment, despite the fact that we appreciate this interesting and original paper, considering the upon mentioned perplexities, we think authors should provide missing information. Thus, we disagree with their conclusion that, on the base of the reported results, that remain very interesting, prospective multi-center studies, comparing TACE with second line chemotherapy are warranted.