and should be considered in T2N0 disease with
high-risk features. Currently, there is no global
consensus on the optimal treatment approach.
Data from various trials have shown benefit for
each approach. Regional preferences are: peri-
operative chemotherapy in Europe; adjuvant
chemoradiotherapy in the United States; and
adjuvant chemotherapy in Asia. In an effort to
better define the optimal treatment approach,
several randomized clinical trials are being
conducted. According to the current NCCN
guidelines, the following treatment approaches
are acceptable and are supported by data in the
trial listed in parentheses:
• Perioperative chemotherapy
° 5-FU/cisplatin (French FNLCC/FCCD
trial) 44 or
° ECF (MAGIC trial)42 or
° ECF modifications: EOX, EOF, ECX
(REAL- 2 trial) 43
• Adjuvant chemoradiotherapy
° 5-FU/leucovorin sandwiched with 5-FU-
based chemoradiation (INT-0116 trial)45
• Adjuvant chemotherapy (after D2 resection)
° Capecitabine/oxaliplatin (CLASSIC trial)52
° Capecitabine/cisplatin (ARTIST trial)48,49
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