Prophylaxis with carbon-adsorbed mitomycin against peritoneal recurrence of gastric cancer

The benefits of surgery plus extensive intraoperative peritoneal lavage (EIPL) for patients with gastric cancer compared with surgery alone: a systematic review and meta-analysis

This study aims to synthesize the benefits of surgery plus extensive intraoperative peritoneal lavage (EIPL) for patients with gastric cancer compared with surgery alone. We searched Pubmed, Embase, Web of Science, Cochrane library, ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform (ICTRP) for randomized controlled trials from 2000 to 2021 according to the inclusion and exclusion criteria. The reference lists of studies meeting the criteria were also screened for additional studies. The quality of these studies was assessed by the Cochrane Collaboration Risk of Bias Tool. An inverse-variance random-effects model of DerSimonian and Laird was used to synthesize the HRs and corresponding 95% CIs of short-term outcomes: hospital mortality and postoperative complications. For long-term outcomes (peritoneal recurrence and 3-year or 5-year overall survival rate), narrative synthesis was used. 4 of 43 studies were included for quantitative analysis. For short-term outcomes, the pooled HRs of hospital mortality and postoperative complications are 0.422 (95%CI: 0.037, 4.790) and 0.774 (95%CI: 0.376, 1.592). For long-term outcomes, despite the inconsistent results, patients receiving EPIL did not have reduced peritoneal recurrence and 3-year or 5-year overall survival rate. Compared with surgery alone, surgery plus EIPL does not have more benefits for patients with gastric cancer.

Predicting postoperative peritoneal metastasis in gastric cancer with serosal invasion using a collagen nomogram

Accurate prediction of peritoneal metastasis for gastric cancer (GC) with serosal invasion is crucial in clinic. The presence of collagen in the tumour microenvironment affects the metastasis of cancer cells. Herein, we propose a collagen signature, which is composed of multiple collagen features in the tumour microenvironment of the serosa derived from multiphoton imaging, to describe the extent of collagen alterations. We find that a high collagen signature is significantly associated with a high risk of peritoneal metastasis (P < 0.001). A competing-risk nomogram including the collagen signature, tumour size, tumour differentiation status and lymph node metastasis is constructed. The nomogram demonstrates satisfactory discrimination and calibration. Thus, the collagen signature in the tumour microenvironment of the gastric serosa is associated with peritoneal metastasis in GC with serosal invasion, and the nomogram can be conveniently used to individually predict the risk of peritoneal metastasis in GC with serosal invasion after radical surgery.

Combined Surgery and Extensive Intraoperative Peritoneal Lavage vs Surgery Alone for Treatment of Locally Advanced Gastric Cancer: The SEIPLUS Randomized Clinical Trial

Importance

Peritoneal metastasis is the most frequent pattern of postoperative recurrence in patients with gastric cancer. Extensive intraoperative peritoneal lavage (EIPL) is a new prophylactic strategy for treatment of peritoneal metastasis of locally advanced gastric cancer; however, the safety and efficacy of EIPL is currently unknown.

Objective

To evaluate short-term outcomes of patients with advanced gastric cancer who received combined surgery and EIPL or surgery alone.

Design, Setting, and Participants

From March 2016 to November 2017, 662 patients with advanced gastric cancer receiving D2 gastrectomy were enrolled in a large, multicenter, randomized clinical trial from 11 centers across China. In total, 329 patients were randomly assigned to receive surgery alone, and 333 patients were randomly assigned to receive surgery plus EIPL. Clinical characteristics, operative findings, and postoperative short-term outcomes were compared between the 2 groups in the intent-to-treat population.

Main Outcomes and Measures

Short-term postoperative complications and mortality.

Results

The present analysis included data from 550 patients, 390 men and 160 women, with a mean (SD) age of 60.8 (10.7) years in the surgery alone group and 60.6 (10.8) in the surgery plus EIPL group. Patients assigned to the surgery plus EIPL group exhibited reduced mortality (0 of 279 patients) compared with those assigned to surgery alone (5 of 271 patients [1.9%]) (difference, 1.9%; 95% CI, 0.3%-3.4%; P = .02). A significant difference in the overall postoperative complication rate was observed between patients receiving surgery alone (46 patients [17.0%]) and those receiving surgery plus EIPL (31 patients [11.1%]) (difference, 5.9%; 95% CI, 0.1%-11.6%; P = .04). Postoperative pain occurred more often following surgery alone (48 patients [17.7%]) than following surgery plus EIPL (30 patients [10.8%]) (difference, 7.0%; 95% CI, 0.8%-13.1%; P = .02).

Conclusions and Relevance

Inclusion of EIPL can increase the safety of D2 gastrectomy and decrease postoperative short-term complications and wound pain. As a new, safe, and simple procedure, EIPL therapy is easily performed anywhere and does not require any special devices or techniques. Our study suggests that patients with advanced gastric cancer appear to be candidates for the EIPL approach.

Trial Registration

ClinicalTrials.gov identifier: NCT02745509.

Pressurized Intraperitoneal Aerosol Chemotherapy, a Palliative Treatment Approach for Patients With Peritoneal Carcinomatosis: Description of Method and Systematic Review of Literature

BACKGROUND

Peritoneal metastases arise in patients with a variety of primary cancers, and are associated with a poor prognosis. Systemic chemotherapy is the mainstay of treatment; however, the morbidity is considerable and the survival benefit is modest. Cytoreductive surgery and heated intraperitoneal chemotherapy is a potentially curative treatment available to a minority of patients; however, most develop recurrent disease. A novel palliative treatment for peritoneal metastases, pressurized intraperitoneal aerosol chemotherapy, has recently been introduced. Pressurized intraperitoneal aerosol chemotherapy utilizes an aerosol of chemotherapy in carbon dioxide gas. It is instilled into the abdomen under pressure via laparoscopic ports. No cytoreduction is performed. Pressurized intraperitoneal aerosol chemotherapy can be repeated at 6-week intervals. Oxaliplatin or cis-platinum and doxorubicin have been used to date.

OBJECTIVE

This study aims to systematically review and evaluate the method, and the preclinical and early clinical results of pressurized intraperitoneal aerosol chemotherapy.

DATA SOURCES

Medline and the Cochrane Library were the data sources for the study.

STUDY SELECTION

Peer-reviewed series of greater than 10 patients, with sufficient patient data, through April 2019, were selected.

INTERVENTION

Patients with peritoneal metastases underwent pressurized intraperitoneal aerosol chemotherapy.

MAIN OUTCOME MEASURES

Patient dropout, histologic tumor response, adverse events, and 30-day mortality were the primary outcomes measured.

RESULTS

A total of 921 patients with peritoneal metastases were brought to the operating room for pressurized intraperitoneal aerosol chemotherapy. The number of pressurized intraperitoneal aerosol chemotherapy treatments administered was as follows: 1 treatment, 862 (94%); 2 treatments, 645 (70%); and 3 treatments, 390 patients (42%). Initial laparoscopic access was not possible in 59 patients (6.4%). Common Terminology Criteria for Adverse Events grade 3 or higher were noted in 13.7% of the patients who, collectively, underwent a total of 2116 treatments. The 30-day mortality was 2.4% (22/921).

LIMITATIONS

This study was limited by the heterogeneity of reported data and primary tumor types and by the lack of long-term survival data.

CONCLUSIONS

Early clinical results are encouraging, but tumor-specific, prospective, randomized trials are needed to compare pressurized intraperitoneal aerosol chemotherapy to systemic chemotherapy. This method has yet to be introduced to the United States. It is another therapeutic option for patients with peritoneal metastases and will broaden the patient base for future clinical trials.

Efficacy and safety of intraperitoneal chemotherapy in patients with advanced gastric cancer: a cumulative meta-analysis of randomized controlled trials

Even when a curative gastrectomy is conducted, the majority of advanced gastric cancer patients with invasion die due to peritoneal recurrence. We performed electronic searches to identify randomized controlled trials published through April 2017 evaluating the effect of intraperitoneal chemotherapy (IPC) on survival rates. We included 23 trials reporting data on 2,767 patients with advanced gastric cancer. Overall, we noted that patients who received IPC had a significantly increased 1-year survival rate, and the treatment effect of IPC on 1-year survival was most prominent in studies conducted in Japan or those with a mean age of less than 60 years. IPC was also associated with an increased incidence of 2-year survival rate, but it was not seen to have this effect in studies conducted in China or Australia or with a mean age greater than 60 years. Similarly, IPC associated with a significantly increased 3-year survival rate, but this difference was not detected in studies conducted in Austria or with a mean age greater than 60 years. IPC has no significant effect on the 5-year survival rate. Finally, IPC was associated with a lower risk of recurrence in patients with advanced gastric cancer. The findings of this study suggest that gastric cancer patients who receive IPC associate with increased 1-year, 2-year, and 3-year survival rates, but this does not extend out to a 5-year survival rate. IPC is also shown to play a protective role against the risk of recurrence in patients with advanced gastric cancer.

Intraperitoneal chemotherapy for gastric cancer with peritoneal metastasis

Peritoneal metastasis is the most frequent pattern of gastric cancer recurrence or metastasis and is a definitive determinant of prognosis. However, an effective means of treating peritoneal disease has not yet been established. Systemic chemotherapy has only a limited effect on peritoneal metastasis, although some progress has been shown in terms of median survival time, especially among patients with a minimal or moderate disease burden. Clinical research related to intraperitoneal administration of anticancer drugs is currently underway. An advantage of intraperitoneal chemotherapy is the ability to achieve high concentrations of anticancer drugs in the peritoneal cavity and the direct exposure of peritoneal deposits and free cancer cells to those drugs. In addition, pharmacokinetic studies with taxanes have shown that these high intraperitoneal drug concentrations are sustained for a considerable length of time, allowing prolonged exposure. As taxanes are the most appropriate drugs for intraperitoneal administration, the development of repeated intraperitoneal chemotherapy using taxanes for gastric cancer peritoneal metastasis-either alone or in combination with systemic chemotherapy-has taken place over the past decade, mostly in Japan. Several phase II trials and a phase III trial have recently demonstrated the efficacy of this therapy, including median survival times of 14.4-24.6 months and one-year overall survival rates of 67-91%. These results may lead to the approval of intraperitoneal taxanes, especially paclitaxel, for official insurance coverage in the near future.

Hyperthermic intraperitoneal chemotherapy (HIPEC) and neoadjuvant chemotherapy as prophylaxis of peritoneal carcinosis from advanced gastric cancer-effects on overall and disease free survival

BACKGROUND

The possibility to enlarge criteria for intra-peritoneal chemotherapy (IPC) to all patients at high-risk to develop peritoneal carcinosis (i.e., with serosal invasion) is still discussed.

METHODS

Retrospective case-control study. Three-groups: advanced-gastric-cancer (AGC) (pT4) without proven carcinosis: prophylactic group (PG), those with PC: treatment group (TG), AGC (pT3-pT4) operated without hyperthermic intraperitoneal chemotherapy (HIPEC), surgery alone group (SG T3, SG T4).

RESULTS

Forty four patients. 26 (59.1%) were male. Sixteen (36%) patients underwent 16 HIPEC: 6 (38%) had AGC (pT4) without PC (PG), 10 (62%) had carcinosis (TG), 28 were operated without HIPEC (SG T3, SG T4). The mean disease free survival (DFS): TG: 7.7 months, SG T4: 21.6 months, SG T3: 27.7 months, PG: 34.5 months. DFS was significantly different for TG (P=0.03, P=0.021, P=0.013 respectively). The mean OS TG: 10 months, SG T4: 27.1 months, SG T3: 28.2 months, PG: 34.6 months. OS was significantly different for TG (P=0.04, P=0.04, P=0.045 respectively). Severe complication rate: TG: 60%, PG: 16.7%, SG T3: 7.7% and SG T4: 25% (P=0.035). Length-of-stay differs significantly (P=0.003); overall length-of-stay: 19.41 days [standard deviation (SD) ±15.03]; TG: 33.01 (SD ±23.08), PG: 20.17 (SD ±6.21), SG T3: 11.33 (SD ±3.22), SG T4: 15.36 (SD ±5.48).

CONCLUSIONS

Prophylactic intraperitoneal chemotherapy associated to neoadjuvant chemotherapy increases the DFS and OS in patients with AGC without carcinosis. More data are needed in order to confirm these results.

Effect of intraperitoneal chemotherapy and peritoneal lavage in positive peritoneal cytology in gastric cancer. Systematic review and meta-analysis

INTRODUCTION

The most common cause of tumour progression in advanced gastric cancer is peritoneal carcinosis (PC). The necessity to increase the survival in advanced diseases suggested to deliver the chemotherapy directly in the peritoneal cavity also in Cy+/PC- and to experiment the effect of massive peritoneal lavage to wash out the tumour cells. The aim of this study is to investigate the gain in term of survival and peritoneal recurrence rate of the intraperitoneal chemotherapy and/or peritoneal lavage in patients with Cy+/PC-.

MATERIAL AND METHODS

A systematic review with meta-analysis of trials about the effect of intraperitoneal chemotherapy (IPC) and/or peritoneal lavage (PL) on positive cytology in gastric cancer without carcinosis.

RESULTS

Three trials have been included (164 patients: 76 received surgery alone, 51 surgery + IPC and 37 surgery + IPC + PL). Two- and five-years survival is increased by IPC (RR = 1.62, RR = 3.10). 2 and 5 years survival is further increased by IPC + PL (RR = 2.33, RR = 6.19). Peritoneal recurrence is reduced by IPC (OR = 0.45) and by IPC + PL (OR = 0.13).

CONCLUSIONS

Two- and five-years overall survival in patients with free cancer cells without carcinosis is incremented by intraperitoneal chemotherapy. Peritoneal lavage further increases these survival rates and also it further decreases the peritoneal recurrence rate.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for gastric cancer and other less common disease histologies: is it time?

Gastric cancer is the fourth most commonly diagnosed cancer worldwide, and once spread to the peritoneum, has a 5-year survival of less than 5%. Recent years have demonstrated advances in the use of cytoreductive surgery (CRS) in combination with heated intraperitoneal chemotherapy (HIPEC) for the treatment of peritoneal carcinomatosis due to various malignancies. The frequent desmoplastic stroma and poor vascularization impeding drug delivery particularly in the diffuse form of gastric cancer is thought to provide a sound rationale for a regionalized treatment approach in this disease. Here, we seek to review the available data to define the role of CRS and HIPEC in gastric cancer metastatic to the peritoneal surface, and furthermore, analyze the use of CRS and HIPEC in malignancies less commonly treated with the regionalized perfusion approach.

Complete versus incomplete cytoreduction in peritoneal carcinosis from gastric cancer, with consideration to PCI cut-off. Systematic review and meta-analysis

INTRODUCTION

The completeness of cytoreduction has been considerated as fundamental in increasing the life expectancy in patients with peritoneal carcinosis (PC) in gastric cancer. However no definitive data about the real effect of complete cytoreduction (CC) have still been published. Moreover the PCI cut-off to attempt CC with a reasonable risk-benefit ratio still lacks.

MATERIAL AND METHODS

A systematic review with meta-analysis of trials of complete vs incomplete cytoreduction in patients with peritoneal carcinosis from GC was performed.

RESULTS

Nine trials have been included (748 patients: 417 with CC0-CC1 and 324 with CC2-CC3 cytoreduction). 1, 2, 3 and 5 years survival is favorable to CC0-CC1 (Risk Ratio: 2.41, 8.18, 8.66, and 7.96 respectively). CC0 vs. CC1 survival benefit at 1 and 3 years: RR 2.28 and 6.36 respectively, favoring CC0. 1, 2, 3 and 5 years survival changes significantly above and below a PCI of 12.

CONCLUSIONS

1, 2, 3 and 5-year overall survival is increased by CC0-CC1 cytoreduction in patients with PC from gastric origin. Moreover CC0 increases the 1 and 3 years survival when compared to CC1 cytoreduction.

Intraperitoneal chemotherapy in advanced gastric cancer. Meta-analysis of randomized trials

INTRODUCTION

An important component of treatment failure in gastric cancer (GC) is cancer dissemination within the peritoneal cavity and nodal metastasis. Intraperitoneal chemotherapy (IPC) is considered to give a fundamental contribute in treating advanced GC. The purpose of the study is to investigate the effects of IPC in patients with advanced GC.

MATERIAL AND METHODS

A systematic review with meta-analysis of randomized controlled trials (RCTs) of IPC + surgery vs. control in patients with advanced GC was performed.

RESULTS

Twenty prospective RCTs have been included (2145 patients: 1152 into surgery + IPC arm and 993 into control arm). Surgery + IPC improves: 1, 2 and 3-year mortality (OR = 0.31, 0.27, 0.29 respectively), 2 and 3-year mortality in patients with loco-regional nodal metastasis (OR = 0.28, 0.16 respectively), 1 and 2-year mortality rate in patients with serosal infiltration (OR = 0.33, 0.27 respectively). Morbidity rate was increased by surgery + IPC (OR = 1.82). The overall recurrence and the peritoneal recurrence rates were improved by surgery + IPC (OR = 0.46 and 0.47 respectively). There was no statistically significant difference in lymph-nodal recurrence rate. The rate of haematogenous metastasis was improved by surgery + IPC (OR = 0.63).

CONCLUSIONS

1, 2 and 3-year overall survival is incremented by the IPC. No differences have been found at 5-year in overall survival rate. 2 and 3-year mortality rates in patients with nodal invasion and 1 and 2-year mortality rates in patients with serosal infiltration are improved by the use of IPC. IPC has positive effect on peritoneal recurrence and distant metastasis. Morbidity rate is incremented by IPC. Loco-regional lymph-nodes invasion in patients affected by advanced gastric cancer is not a contraindication to IPC.

A proposal of a practical and optimal prophylactic strategy for peritoneal recurrence

Peritoneal metastasis, which often arises in patients with advanced gastric cancer, is well known as a miserable and ill-fated disease. Once peritoneal metastasis is formed, it is extremely difficult to defeat. We advocated EIPL (extensive intraoperative peritoneal lavage) as a useful and practical adjuvant surgical technique for those gastric cancer patients who are likely to suffer from peritoneal recurrence. In this paper, we review the effect of EIPL therapy on prevention of peritoneal recurrence on patients with peritoneal free cancer cells without overt peritoneal metastasis (CY+/P−) through the prospective randomized study, and we verified its potential as an optimal and standard prophylactic therapeutic strategy for peritoneal recurrence.

Free peritoneal tumor cells detection in gastric and colorectal cancer patients

BACKGROUND

Free peritoneal tumor cells (FPTC) derive from the detachment of primary cancer and may result in peritoneal carcinomatosis. Since peritoneal lavage cytology has low sensitivity in detecting FPTC, our aim was to estimate the clinical relevance of FPTC detected using an approach based on multiple molecular techniques.

MATERIALS AND METHODS

Samples of peritoneal lavage were collected from 27 gastric and 48 colorectal cancer patients. FPTC recovery and detection from peritoneal washes was performed by cytological examination and immunomagnetic enrichment for epithelial cells followed by immunofluorescence analysis for epithelial marker EpCAM/CD326 and carcinoembryonic antigen (CEA). CEA and CK20 mRNA levels were quantified using a real-time qRT-PCR system.

RESULTS

For gastric carcinoma the FPTC positivity rate acquired by cytology, immunofluorescence and qRT-PCR was 14.8%, 14.8%, and 78% and for colorectal carcinoma was 0%, 17%, and 42%, respectively. qRT-PCR positivity was correlated with a poor cancer-specific survival and time-to-recurrence rates in both gastric and colorectal carcinoma.

CONCLUSIONS

Epithelial immunoenrichment and immunofluorescence analysis allows unequivocal identification of the FPTC. The real time qRT-PCR showed higher sensitivity for the detection of CEA and CK20 mRNA levels and confirmed its prognostic value in gastrointestinal cancers.

Pilot study of a combination of S-1 and paclitaxel for patients with peritoneal metastasis from gastric cancer

BACKGROUND

This pilot study was carried out to evaluate the efficacy of chemotherapy for patients with peritoneal dissemination from gastric cancer or positive lavage cytology diagnosed by staging laparoscopy.

METHODS

Sixteen patients were enrolled. Paclitaxel was administered at 120 mg/m(2) on day 1 and S-1 was administered orally at 80 mg/m(2) for 14 consecutive days, followed by a 1-week rest, as one course. After five courses of this therapy, the primary gastric tumors were evaluated and second-look laparoscopy was performed for patients showing partial response or stable disease with clinical benefit.

RESULTS

Partial response or stable disease with clinical benefit was confirmed in seven and five patients, respectively, and these patients underwent second-look laparoscopy. No viable cancer cells were detected on cytopathological investigation during second-look laparoscopy in 9 patients who underwent surgical treatment. The intent-to-treat response rate for gastric tumor was 44% and the rate of disappearance of peritoneal metastasis was 38% (6 cases) at surgery. The median survival time was 555 days. Leucopenia of grade 3 and neutropenia of grade 3 were recognized in two and three patients, respectively.

CONCLUSION

This chemotherapy regimen may be an acceptable option for patients with peritoneal dissemination. We plan to study this regimen further in gastric cancer patients with peritoneal dissemination.

Phase I study of intraperitoneal irinotecan in patients with gastric adenocarcinoma with peritoneal seeding

PURPOSE

The objectives of this phase I study were to determine the maximum-tolerated dose (MTD), dose-limiting toxicities (DLTs), and preliminary efficacy of intraperitoneally administered irinotecan (CPT-11) in gastric cancer patients with peritoneal seeding.

EXPERIMENTAL DESIGN

Gastric adenocarcinoma patients with surgical biopsy proven peritoneal seeding were enrolled at the time of surgery. Prior to IP chemotherapy, patients underwent palliative gastrectomy and CAPD catheter insertion in which CPT-11 was administered on postoperative day 1. The IP CPT-11 was initiated at 50 mg/m(2), which was escalated to 100, 150, 200, 250, and 300 mg/m(2). IP CPT-11 chemotherapy was repeated every 3 weeks.

RESULTS

Seventeen patients received a total of 56 cycles at five different CPT-11 dose levels. The DLTs were neutropenic fever, neutropenia, and diarrhea. At the dose level 2 (100 mg/m(2)), there were one DLTs in one of the first cohort of three patients, but no DLTs at the second cohort of this level. At the dose level 5 (250 mg/m(2)), two DLTs were detected in the first two patients; thus, the accrual was stopped resulting in the recommended dose of IP CPT-11 of 200 mg/m(2). Median progression-free survival was 8.6 months (95% CI, 5.9,11.2), and median overall survival was 15.6 months (95% CI, 8.4,22.8). Pharmacokinetic results of the study showed that the C (max) of peritoneal SN-38 was achieved earlier than that of plasma SN-38.

CONCLUSIONS

Intraperitoneally administered CPT-11 was feasible and tolerable. Further, phase II study of IP CPT-11 in gastric cancer patients with peritoneal seeding is warranted.

Recent results of therapy for scirrhous gastric cancer

The prognosis of patients with scirrhous gastric cancer (SGC) is extremely poor. However, recent advances in therapeutic strategies against SGC, using effective anticancer drugs, have prolonged the survival of patients with SGC. This paper reviews the recent therapeutic outcomes of this type of gastric cancer and introduces a new treatment protocol for SGC.

Pilot study of intraperitoneal administration of paclitaxel and oral S-1 for patients with peritoneal metastasis due to advanced gastric cancer

BACKGROUND

There is no standard treatment for peritoneal dissemination from gastric cancer. A novel combination chemotherapy has been introduced for patients with advanced gastric cancer with peritoneal metastasis.

METHODS

This pilot study was performed on four patients to confirm safety and efficacy. They were diagnosed with unresectable gastric cancer with severe peritoneal dissemination by staging laparoscopy, or with metastasis to the transverse colon. We selected combined chemotherapy with both paclitaxel and S-1. Paclitaxel at 60 mg/m(2) or 60 mg/body was administered intraperitoneally on days 1 and 8 and S-1, at 80-120 mg/body, was administered orally for 14 days followed by 7 days' rest, as one course. After five courses of this therapy, the primary gastric tumors were evaluated by conventional examinations, and second-look laparoscopy was performed to assess the efficacy of the treatment against the peritoneal metastases.

RESULTS

After five courses, primary tumor reductions were confirmed, and no cancer cells were detected on pathocytological investigation during second-look laparoscopy in any of the patients. Three patients underwent total gastrectomy with lymph node dissection and one underwent left upper abdominal evisceration. Final histological staging showed two stage 3 and two stage 4 patients. The intraperitoneal administration of paclitaxel and the oral administration of S-1 were well tolerated. Three patients died, at 8, 15, and 29 months, respectively, after the initial treatment, and one has been alive for 54 months without recurrence.

CONCLUSION

This chemotherapy can be used in the treatment of patients with peritoneal metastasis of gastric cancer.

Phase II study of weekly paclitaxel by one-hour infusion for advanced gastric cancer

PURPOSE

A phase clinical II trial was conducted to determine the antitumor activity and toxicity of weekly paclitaxel administered to patients with advanced gastric cancer.

METHODS

Sixty-eight patients with advanced gastric cancer and performance status 0-2 were treated with 80 mg/m2 paclitaxel over 1 h following a short course of premedication with dexamethasone, diphenhydramine, and ranitidine administered 30 min prior to the delivery of the paclitaxel. In principle, the treatment was repeated weekly for three courses, followed by a 1-week rest.

RESULTS

Objective responses were observed in 12 of 68 patients (17.6%; 95% confidence interval: 9.5%-28.8%). Two of fourteen (14.2%) patients with no prior chemotherapy and 10 of 54 (18.5%) patients previously treated for metastatic disease developed a partial response. The median therapeutic duration and the median survival time were 96 days and 222 days, respectively. In 212 (85.5%) of 248 total cycles, the original dose of 80 mg/m2 of paclitaxel was administered and was well tolerated. Fourteen of 68 patients (20.1%) experienced grade 3 or 4 neutropenia. Grade 1 or 2 peripheral neuropathy occurred in 10 patients (14.7%).

CONCLUSION

Weekly paclitaxel therapy is an active and safe treatment for advanced gastric cancer.

Water-dispersed single-wall carbon nanohorns as drug carriers for local cancer chemotherapy

Aim: Functional analyses of water-dispersed carbon nanohorns with antitumor activity were performed to explore their potential as a drug carrier for local cancer chemotherapy. Materials & methods: Water-dispersed carbon nanohorns were prepared through adsorption of polyethylene glycol-doxorubicin conjugate (PEG–DXR) onto oxidized single-wall carbon nanohorns (oxSWNHs). PEG–DXR-bound oxSWNHs were administered intratumorally to human nonsmall cell lung cancer-cell NCI-H460-bearing mice. Results & discussion: When injected intratumorally, PEG–DXR-bound oxSWNHs caused significant retardation of tumor growth associated with prolonged DXR retention in the tumor. In accordance with this DXR retention, a large number of oxSWNH agglomerates was found in the periphery of the tumor. Histological analyses showed migration of oxSWNHs to the axillary lymph node, which is a major site of breast cancer metastasis near the tumor, possibly by means of interstitial lymphatic-fluid transport. Conclusions: These results suggest that water-dispersed oxSWNHs may thus be useful as a drug carrier for local chemotherapy.

Foreign body granuloma of activated charcoal

We present foreign body granulomas induced by activated charcoal from intraperitoneal chemotherapy and mimicked peritoneal metastases in the patients with gastric cancer. On CT, they were manifested as a peritoneal mass or thickening with variable shapes, including oval, round, bizarre, linear and even a molded shape due to where they were lodged, such as the pelvis and paracolic gutter. All the lesions showed high attenuation relative to muscle on the precontrast CT and showed positive findings on PET/CT.

A carbohydrate recognition-based drug delivery and controlled release system using intraperitoneal macrophages as a cellular vehicle

The lymphoid tissue in the omentum, at the so-called milky spots, is known as an initial place for disseminated cancer cells to develop into solid tumors. In the present study, i.p. macrophages significantly took up oligomannose-coated liposomes (OMLs) that were injected into the peritoneal cavity, and then gradually accumulated in the omentum and the other lymphoid tissues within 24 hours of i.p. injection of OMLs. When 5-fluorouracil (5-FU) was encapsulated in the OMLs, >60% of administered 5-FU accumulated in the omentum. Treatment of macrophages at 39 degrees C for 30 minutes led to the release of 5-FU from the macrophages, suggesting that controlled release from macrophages could be achieved by mild hyperthermia. We encased magnetic nanoparticles, which are known to convert electromagnetic energy to heat in the OMLs to achieve in vivo hyperthermia at the site. Using this system in a mouse i.p. metastasis model, we successfully controlled tumor development by coadministration of OML-encased 5-FU and OML-encased magnetic nanoparticles, followed by treatment with an alternating magnetic field. No apparent reduction was seen in tumor growth with the administration of OML-encased magnetic nanoparticles or OML-encased 5-FU alone. Thus, we have established the use of i.p. macrophages as a novel drug delivery system for the control of cancer metastatic to milky spots.

Comparison of intraperitoneal with intravenous administration of taxol in experimental peritoneal carcinomatosis

BACKGROUND

Recurrent tumor growth of colorectal carcinoma at the peritoneal site remains an unsolved problem. The aim of this study was to investigate whether the substance taxol (paclitaxel) can alter intraperitoneal tumor spread using different modes of drug application.

METHODS

Intraperitoneal tumor growth was induced using a tumor cell transfer model (10(6) cells) in rats divided into 3 groups: (1) taxol was applied directly into the abdominal cavity, intraperitoneally or intravenously, immediately following intraperitoneal tumor cell transfer; (2) early postoperative intraperitoneal and intravenous chemotherapy was administered on days 5, 10 and 15 after surgical intervention using an intraperitoneal or intravenous port-a-cath; (3) control group. Thirty days after tumor cell transfer, rats were sacrificed, and tumor weight, number of nodes (at greater omentum and peritoneum) and ascites volume were determined.

RESULTS

Taxol generated a significant inhibitory effect on peritoneal tumor growth. Direct intraoperative intraperitoneal application of taxol induced a more pronounced effect compared with early postoperative intraperitoneal application of the antineoplastic drug. Both application modes were superior to the intravenous route (no significant effect).

CONCLUSION

Taxol appears to be a potential chemotherapeutic drug providing a significant effect in the therapeutic management of peritoneal carcinomatosis under experimental conditions. Combination of taxol with cytostatic agents and new drugs generating different effector mechanisms may help to further diminish or even to prevent intraperitoneal tumor growth.

A systematic review and meta-analysis of the randomized controlled trials on adjuvant intraperitoneal chemotherapy for resectable gastric cancer

BACKGROUND

The purpose of this systematic review and meta-analysis was to determine the effectiveness and safety of adjuvant intraperitoneal chemotherapy for patients with locally advanced resectable gastric cancer.

METHODS

Studies eligible for this systematic review included those in which patients with gastric cancer were randomly assigned to receive surgery combined with intraperitoneal chemotherapy versus surgery without intraperitoneal chemotherapy. There were no language restrictions. After independent quality assessment and data extraction, data were pooled for meta-analysis.

RESULTS

Thirteen reports of randomized controlled trials (RCTs) were included for quality appraisal and data extraction. Ten reports were judged to be of fair quality and subjected to meta-analysis. A significant improvement in survival was associated with hyperthermic intraoperative intraperitoneal chemotherapy (HIIC) alone (hazard ratio [HR] = 0.60; 95% CI = 0.43 to 0.83; p = 0.002) or HIIC combined with early postoperative intraperitoneal chemotherapy (EPIC) (HR = 0.45; 95% CI = 0.29 to 0.68; p = 0.0002). There was a trend towards survival improvement with normothermic intraoperative intraperitoneal chemotherapy (p = 0.06), but this was not significant with either EPIC alone or delayed postoperative intraperitoneal chemotherapy. Intraperitoneal chemotherapy was also found to be associated with higher risks of intra-abdominal abscess (RR = 2.37; 95% CI = 1.32 to 4.26; p = 0.003) and neutropenia (RR = 4.33; 95% CI = 1.49 to 12.61; p = 0.007).

CONCLUSIONS

The present meta-analysis indicates that HIIC with or without EPIC after resection of advanced gastric primary cancer is associated with improved overall survival. However, increased risk of intra-abdominal abscess and neutropenia are also demonstrated.

Prognostic significance of peritoneal washing cytology in Thai patients with gastric adenocarcinoma undergoing curative D2 gastrectomy

BACKGROUND

The aim of the present study was to determine the prognostic significance of peritoneal washing cytology (PWC) among Thai patients with gastric adenocarcinoma.

METHODS

Medical charts of 97 patients with gastric adenocarcinoma who underwent curative D2 gastrectomy between October 1995 and September 2005 were reviewed.

RESULTS

A total of 22 patients (23%) had positive PWC. Factors significantly associated with positive PWC included tumor location, macroscopic findings, histology, depth of tumor invasion, nodal involvement, TNM stage, and angiolymphatic invasion. Positive PWC was found only in tumors invading the serosa. All patients with positive PWC developed peritoneal recurrence. The sensitivity and specificity of positive PWC in predicting peritoneal recurrence were 61% and 100%, respectively. The overall 5-year survival rates for patients with positive and negative PWC were 0% and 75%, respectively.

CONCLUSION

Gastric adenocarcinoma with positive PWC should be considered stage IV disease. PWC should be included in the staging of gastric adenocarcinoma.

Early Postoperative Intraperitoneal Chemotherapy Following Cytoreductive Surgery in Patients with Very Advanced Gastric Cancer

BACKGROUND

The survival of patients with stage IV gastric cancer is poor due to frequent peritoneal failure. The aim of this study was to investigate the impact of early postoperative intraperitoneal chemotherapy (EPIC) after cytoreductive surgery on the long-term survival of these patients, as determined by residual disease status.

METHODS

A total of 154 patients with stage IV gastric cancer were enrolled in our study. All patients underwent potentially curative or palliative resections. After surgery, the residual disease states of the patients were recorded. All patients received EPIC.

RESULTS

Of all 154 patients, R0 resection was achieved in 37, R1 in 56, and R2 in 61. All patients received a mean of 4.3 EPIC perfusions. After a mean followup period of 29 months, 14 patients remained alive. The median survival of all 154 patients was 11.4 months. Survival times were analyzed according to the type of residual tumor; the median survival time was 25.5 months in the R0 group, 15.6 months in the R1 group, and 7.2 months in the R2 group (p < .001). Upon multivariate analysis, the residual tumor states and the cycle of EPIC perfusion were found to be independent prognostic predictors (p < .001 and p = .018, respectively).

CONCLUSIONS

The residual tumor status is the most important predictor for the survival of very advanced gastric cancer patients who received cytoreductive surgery and EPIC. Therefore, complete cytoreductive surgery yielding R0 resection is mandatory for achieving the beneficial effects of EPIC.

A review of adjuvant therapy for resected primary gastric cancer with an update on Taegu's phase III trial with intraperitoneal chemotherapy

AIMS

Because patients with advanced gastric cancers have less than 50% chance of cure after R0 resection, the need for an adjuvant treatment to eradicate residual microscopic disease is clear. The major treatment strategy during the last decades has been postoperative systemic therapy. The results of published trials were reviewed. And, perioperative intraperitoneal chemotherapy as an adjuvant to potentially curative surgery was evaluated.

METHODS

A literature search on this topic was performed for articles relating to clinical trials using adjuvant chemotherapy in the management of gastric cancer. Subset analyses of Taegu's phase III trial of early postoperative intraperitoneal chemotherapy were performed.

RESULTS

Even after extended lymphadenectomy, the peritoneal surface and resection site had a high incidence of recurrence. Postoperative systemic chemotherapy treatment regimens available in the past showed no major improvement in survival. One of new approaches currently undergoing study was intraperitoneal chemotherapy given in the perioperative period. The Taegu data showed this treatment reduced the incidence of peritoneal recurrence and thereby improved the survival rate after potentially curative surgery for gastric cancer.

CONCLUSIONS

The eradication of micrometastatic foci in the peritoneal cavity can be achieved by the perioperative intraperitoneal administration of chemotherapeutic agents. Patients with serosa-positive gastric cancer are most likely to benefit from adjuvant intraperitoneal chemotherapy.

Prognostic significance of peritoneal lavage cytology in gastric cancer in Singapore

BACKGROUND

Peritoneal lavage cytology has been included as part of the staging process in the 13th edition of the Japanese Classification of Gastric Cancer. However, this procedure has neither been studied nor established in our population. We aimed to evaluate its prognostic relevance among our patients with gastric cancer.

METHODS

A total of 142 consecutive patients with gastric carcinoma were recruited prospectively. All had histologically proven gastric carcinomas and had undergone laparotomy and intraoperative peritoneal lavage for cytological examination at Singapore General Hospital. The fluid recovered was centrifuged and stained by the Papanicolau method. All patients were followed up with endpoints of cancer recurrence and mortality.

RESULTS

There were 91 men and 51 women; 36 patients (25.4%) had positive peritoneal lavage. Patients with advanced macroscopic features, presence of vascular invasion, nodal involvement, advanced depth of tumor invasion and metastatic disease tended to have positive lavage, by univariate logistic regression analysis. Despite curative resections, patients with positive cytology had a more dismal disease-free survival (mean, 27 months vs 53 months; P < 0.0001 by log rank test) and higher recurrence rate (54.5% vs 19.3%; P = 0.007 by log rank test). There was also a trend towards earlier recurrences (median, 8 months vs 11 months; P = 0.37). By multivariate Cox regression stepwise analysis, advanced depth of tumor invasion and positive lavage cytology were found to be independent poor prognostic factors for disease-free survival.

CONCLUSION

Positive peritoneal lavage cytology correlated well with advanced features of gastric cancer. It is an independent poor prognostic factor and the procedure should be routinely performed. Integration of lavage status into our current staging systems may serve as a guide for adjuvant therapeutic options to improve the survival of gastric cancer in our population.

Intraperitoneal Versus Intravenous CPT-11 Given Intra- and Postoperatively for Peritoneal Carcinomatosis in a Rat Model

PURPOSE

Peritoneal recurrence after resection of colorectal carcinoma is still a major concern. We investigated whether the novel cytostatic drug, CPT-11 (Irinotecan), delivered intraperitoneally (i.p.) and intravenously (i.v.), could inhibit intraperitoneal tumor spread in a rat model.

METHODS

We induced intraperitoneal tumor growth using a tumor cell transfer model (10(6) cells) and divided the rats into the following five groups of eight: group IP1, given CPT-11 i.p. immediately after intraperitoneal tumor cell transfer; group IV1, given CPT-11 i.v. immediately after intraperitoneal tumor cell transfer; group IP2, given CPT-11 i.p. on postoperative days (PODs) 5, 10, and 15; group IV2, given CPT-11 on PODs 5, 10, and 15; and a control group. The rats were killed 30 days after tumor cell transfer, and the tumor weight, number of nodes in the greater omentum and peritoneum, presence of metastases in the liver and lungs, and ascites volume were determined.

RESULTS

CPT-11 inhibited peritoneal tumor growth significantly. The direct intraoperative intraperitoneal application induced a more pronounced effect than the early postoperative intraperitoneal application, but both these application modes were superior to the intravenous route, which had no significant effect.

CONCLUSION

CPT-11 was highly efficacious against peritoneal carcinomatosis in this experimental model. The combination of CPT-11 with other cytostatic agents and drugs generating different effector mechanisms may diminish or even prevent intraperitoneal tumor growth.

Adjuvant and neoadjuvant therapy for gastric cancer

Although the incidence of gastric cancer is decreasing, it remains a significant source of cancer-related mortality. Surgery remains the best chance for cure from gastric cancer. Adjuvant and neoadjuvant therapy have played increasing roles in attempting to reduce the disease-specific mortality and prolong survival. In this article, the authors review the literature and summarize the salient points regarding the roles of adjuvant and neoadjuvant therapy for gastric cancer.

Gastric cancer

Gastric cancer is one of the most common cancers and one of the most frequent causes of cancer-related deaths. The incidence, diagnostic studies, and therapeutic options have undergone important changes in the last decades, but the prognosis for gastric cancer patients remains poor, especially in more advanced stages. Surgery is the mainstay of treatment of this disease, even if it is associated with a high rate of locoregional and distant recurrence. There is ongoing debate regarding the role of adjuvant treatment In advanced disease, palliation of symptoms, rather than cure, is the primary goal of patient management. Several combination therapies have been developed and have been examined in phase III trials; however, in most cases, they have failed to demonstrate a survival advantage over the reference arm. This review summarizes the most important recommendations for the management of patients with gastric cancer.

Suppression of peritoneal implantation of gastric cancer cells by adenovirus vector-mediated NK4 expression

Peritoneal dissemination is the most common mode of metastasis in gastric cancer. We previously reported the importance of milky spots (MS), peritoneal lymphoid tissues, as selective sites of cancer implantation in peritoneal dissemination. In the present study, we first demonstrated that intraperitoneal injection of adenovirus vector encoding the GFP gene into tumor-free nude mice resulted in GFP expression at omental and mesenteric MS; MS macrophages were target cells for adenovirus infection. We confirmed that intraperitoneal injection of adenovirus vector encoding the NK4 gene (AdNK4) resulted in NK4 production localized to the peritoneal cavity, especially the omentum. Adenovirus vector-mediated MS-selective transgene expression was markedly impaired in tumor-bearing mice whose MS had already been replaced by infiltrating cancer cells. However, prior injection of AdNK4 successfully inhibited MS-selective cancer cell implantation, resulting in suppression of peritoneal dissemination and prolongation of survival. Adenovirus vector-mediated MS-selective delivery of a therapeutic gene may prevent peritoneal dissemination of gastric cancer.

Preoperative intraperitoneal chemotherapy for patients with serosa-infiltrating gastric cancer

BACKGROUND AND OBJECTIVES

Serosa-infiltrating gastric cancer poses a high risk for peritoneal recurrence. This study examined the feasibility and efficacy of preoperative intraperitoneal (i.p.) chemotherapy for such cancer.

METHODS

Patients with serosa-infiltrating tumors, diagnosed by conventional examinations as well as by staging laparoscopy, were enrolled in this study. Those with unresectable T4 tumors, visible peritoneal metastasis or distant organ metastasis were excluded. Twenty-five eligible patients received preoperative i.p. chemotherapy, which consisted of i.p. injection of 20 mg of mitomycin C on day 1 and 10 mg of cisplatin for 5 days, followed by surgery.

RESULTS

Of the 25 patients, 24 underwent gastrectomy with lymph node dissection and 1 underwent palliative gastrojejunostomy. The curability of the surgery was curability A in 6, B in 16, and C in 3. Preoperative T stages (T3 in 21 and T4 in 4) were downstaged postoperatively (T1 in 1, T2 in 10, T3 in 11, and T4 in 3). The 1- and 2-year overall survival was 83.3 and 51.3%, respectively. The median survival time was 24.4 months. The toxicity of the preoperative treatment was tolerable and no serious postoperative complication was seen.

CONCLUSIONS

Preoperative i.p. chemotherapy seems to be a safe and effective therapy for serosa-infiltrating gastric cancer. Randomized clinical trials comparing preoperative i.p. chemotherapy followed by surgery and surgery alone are needed.

Survival benefit of metastasectomy for Krukenberg tumors from gastric cancer

OBJECTIVE

An optimal treatment strategy for ovarian metastases of gastric cancer has not been clearly established. The aim of this study was to examine the role of a metastasectomy in the management of metachronous Krukenberg tumors after curative surgery for gastric cancer.

METHODS

Among 1235 female patients who had undergone a curative gastric resection for stomach cancer between 1987 and 1998, 54 (4.4%) developed Krukenberg tumors as a first recurrence without evidence of a distant metastasis. Of these 54 patients, 33 underwent a metastasectomy while 21 did not. The survival duration between the two groups was analyzed and compared.

RESULTS

The clinicopathological features of Krukenberg tumors as well as those of the primary cancers in the two groups were similar. All 33 patients in the resection group underwent subsequent adjuvant chemotherapy, including the 7 who received intraperitoneal chemotherapy. The 21 patients in the non-resection group were managed by either systemic chemotherapy (n = 16) or supportive care (n = 5) alone. The median survival duration of all the patients was 9 months (95% confidence interval, 3-15 months). The median survival time in the resection group was 17 months (95% confidence interval, 10-24 months), which was significantly longer than that in the non-resection group, 3 months (95% confidence interval, 2-4 months) (P < 0.001).

CONCLUSION

Our results suggest that a metastasectomy was associated with an improved survival in patients with metachronous Krukenberg tumors from gastric cancer. These data offer a strong argument in favor of performing metastasectomy for Krukenberg tumors in the absence of an obvious distant metastasis.

Outcome of surgical treatment for patients with scirrhous carcinoma of the stomach

BACKGROUND

Postoperative survival in patients with scirrhous gastric carcinoma is poorer than that in patients with other gastric carcinomas.

METHODS

We retrospectively examined outcome in patients with scirrhous gastric carcinoma who underwent gastrectomy to determine how to increase postoperative survival. Postoperative survival in patients with scirrhous gastric carcinoma was compared with that in patients having other gastric cancers overall and by disease stage. Prognostic factors were examined for all patients including those with stage III disease.

RESULTS

By multivariate analysis, disease stage, patient age, and scirrhous carcinoma were significant prognostic factors. Five-year survival in patients with stage III scirrhous carcinoma was significantly worse than those with other stage III gastric carcinomas. Extent of lymphadenectomy was one of the variables influencing survival in patients with stage III scirrhous carcinoma.

CONCLUSIONS

Gastrectomy with extended lymphadenectomy should be performed to maximize survival in patients with stage III scirrhous gastric carcinoma.

Transduction of soluble Flt-1 gene to peritoneal mesothelial cells can effectively suppress peritoneal metastasis of gastric cancer

The prognosis of gastric cancer with peritoneal metastasis has not improved. Despite many promising studies, gene therapy has limited clinical application because of the lack of suitable vector systems to enable selective gene transduction to tumor cells. The aim of this study was to clarify whether gene therapy targeted to peritoneal mesothelial cells (PMCs) can inhibit peritoneal dissemination of gastric cancer. In vitro experiments showed that adenovirus expressing LacZ infected human omental tissue-derived PMCs more efficiently than human gastric cancer cell lines MKN1 and MKN45. When adenovirus expressing LacZ was injected into the peritoneal cavity of nude mice, the expression was detected in the peritoneum for at least 4 weeks. Furthermore, when adenovirus expressing soluble Flt-1 (Ad-sFLT-1) was i.p. administered in vivo, a high level of sFlt-1 protein could be detected in peritoneal lavage for 8 weeks. When MKN45 cells were i.p. inoculated 3 days after adenoviral vector injection, Ad-sFLT-1 markedly reduced the number of metastatic nodules larger than 1 mm in diameter on the peritoneal surface, and significantly prolonged the survival of nude mice without any significant side effects. Thus, peritoneal dissemination was significantly suppressed by a single i.p. injection of Ad-sFlt-1. Anti-angiogenic gene therapy targeted to PMCs could be a novel and practical strategy against peritoneal dissemination of gastric cancer, because it does not require tumor-specific gene transfer.

Overexpression of dopa decarboxylase in peritoneal dissemination of gastric cancer and its potential as a novel marker for the detection of peritoneal micrometastases with real-time RT-PCR

We previously performed a global analysis of the gene expression of gastric cancer cell lines established from metastases to the peritoneal cavity with the cDNA microarray method, which made it possible to analyse the expression of approximately 21 168 genes for the identification of novel markers for the detection of micrometastases in the peritoneal cavity. One of the upregulated genes is dopa decarboxylase (DDC), which is responsible for the synthesis of the key neurotransmitters dopamine and serotonine. We have examined its potential as a novel marker for the detection of peritoneal micrometastases of gastric cancer.

DDC mRNA in the peritoneal wash from 112 gastric cancer patients was quantified for comparison of carcinoembryonic antigen (CEA) mRNA by means of real-time reverse transcriptase–polymerase chain reaction (RT–PCR) with a fluorescently labelled probe to predict peritoneal recurrence. The quantity of DDC and CEA correlated with wall penetration. Real-time RT–PCR could quantitate 10–10⁶ DDC-expressing gastric cancer cells per 10⁷ mesothelial cells. The cutoff value was set at the upper limit of the quantitative value for noncancer patients, and those above this cutoff value constituted the micrometastasis (MM+) group. Of 15 cases with peritoneal dissemination, 13 were MM+DDC (87% sensitivity), and one of 48 t1 cases was MM+ (98% specificity). DDC levels in peritoneal washes from patients with synchronous peritoneal metastases were more than 50 times higher than in those from patients without metastasis (P<0.01). For 15 cases of peritoneal dissemination (seven cases were cytologically positive), DDC was positive in 13 cases (87% sensitivity), but CEA failed to detect micrometastases in four cases (73% sensitivity), indicating that DDC is in some cases superior to CEA for the detection of peritoneal micrometastases of gastric cancer in terms of sensitivity as well as specificity, especially for poorly differentiated adenocarcinomas. A combination of CEA and DDC improved the accuracy of diagnosis up to 94%.

These results suggest that DDC is potentially a novel marker for peritoneal dissemination of gastric cancer and that quantitative RT–PCR of DDC is reliable and efficient for the selection of patients for adjuvant intraperitoneal chemotherapy to prevent peritoneal recurrence.

Magnitude of serosal changes predicts peritoneal recurrence of gastric cancer

BACKGROUND

Peritoneal dissemination is the most frequent mode of recurrence in patients with gastric cancer. We tried to identify factors that predict peritoneal recurrence with high sensitivity.

STUDY DESIGN

Clinical and pathologic data from 587 consecutive patients with gastric cancer were reviewed retrospectively. The stepwise Cox proportional hazards regression model was used to assess the prognostic significance of the magnitude of serosal changes. Multiple stepwise logistic regression analysis was used to determine factors associated with peritoneal recurrence in 375 patients who underwent curative resection.

RESULTS

The 5-year survival rate of patients with S2 disease (greatest dimension of macroscopic serosal changes >/= 2.5 cm) was 18%, which was worse than S0 (no serosal changes) and S1 disease (macroscopic serosal changes < 2.5 cm)(p < 0.001). Patients with S0 tumors who underwent curative resection had the best 5-year survival rate. Multivariate analyses indicated that the magnitude of serosal changes was an independent prognostic factor for survival both overall and after curative resection. Logistic regression analysis showed that peritoneal recurrence was more than four times as likely with S2 than with S0 or S1 tumors. The sensitivity for predicting peritoneal recurrence was 79%; the sensitivity of cytologic examination was 38%.

CONCLUSIONS

Magnitude of serosal changes is easy to measure intraoperatively and predicts peritoneal recurrence of gastric cancer with greater sensitivity than conventional peritoneal lavage cytology.

Individualizing therapy in gastric cancer

Although its incidence in developed countries has declined, gastric cancer remains one of the most common human malignancies. In western countries a shift from distal to proximal tumors has been noted during the past 15 years. Today, surgery is no longer the only treatment modality of gastric cancer, with the help of modern and sophisticated staging procedures it becomes increasingly possible to individually tailor therapy. Operative morbidity and mortality has markedly decreased. The importance of surgical expertise for short- as well as long-term outcome is emphasized. The knowledge of adequate surgery together with the use of combined modalities opens the door to the amelioration of the still dismal prognosis for patients with gastric cancer. This paper reviews the modern approach to gastric cancer using an individualized treatment concept.

Impact of perioperative intraperitoneal chemotherapy on the treatment of primary gastric cancer

Perioperative intraperitoneal chemotherapy provides effective prevention of peritoneal recurrence after resection in advanced gastric cancer, especially in gastric cancer with serosal invasion. With improved local-regional control, improved survival rate for advanced gastric cancer is achieved. This type of regional chemotherapy is an independent treatment-related prognostic factor for advanced gastric cancer. There are several methods of perioperative intraperitoneal chemotherapy. Among them, early postoperative intraperitoneal chemotherapy is simple and easy to perform.

Intraperitoneal antineoplastic drug delivery: rationale and results

The use of intraperitoneal drug delivery in the treatment of malignant disease confined to the peritoneal cavity is based on the theoretical potential for increased exposure of the tumour to antineoplastic agents leading to improved cytotoxicity. Phase I studies have explored the safety and pharmacokinetic advantage of the regional administration of several drugs, including cisplatin (10 times higher than systemic delivery) and paclitaxel (1000 times higher). Phase II trials of second-line intraperitoneal chemotherapy of ovarian cancer, generally with cisplatin, have shown the potential for patients to achieve surgically-documented complete responses. Randomised trials of second-line regional therapy in patients with ovarian cancer have yet to be conducted, although non-randomised single institution experience has suggested the potential for long-term disease-free survival with this strategy. By contrast, several well-planned randomised trials of first-line intraperitoneal chemotherapy of small-volume residual advanced ovarian cancer after primary surgical cytoreduction have reported a survival advantage with regional drug delivery. Although a rationale can be proposed for intraperitoneal antineoplastic drug delivery in non-ovarian malignant disease involving the peritoneal cavity, current data do not support the use of this strategy outside the confines of well-designed clinical trials.

Curative treatment of gastric cancer: towards a multidisciplinary approach?

Despite marked decreases in incidence over the last century, particularly in developed countries, gastric cancer is still the second-most common tumor worldwide. Surgery remains the gold standard for the cure of locoregional disease. However, in most countries, the diagnosis is made at an advanced stage, and the 5-year survival for surgically resectable disease stays far below 50%. The efficacy of chemotherapy and/or radiation therapy in addition to surgery has been actively studied over the last 30 years. Unfortunately, with few exceptions, most studies of adjuvant therapy in gastric cancer have given deceiving results. The purpose of this review is to address the reasons for our failure to objectivate an improvement in the cure of gastric cancer with adjuvant treatment in most trials, and to consider potential solutions. The low efficacy of chemotherapy regimens available up to now may have hampered our progress. In addition, many previous studies suffered limitations of design or methodology (e.g. low accrual, inadequate disease stage selection, inadequate surgical treatment) that may have obscured a treatment effect. Furthermore, the reduced treatment tolerance of post-gastrectomy patients, perhaps due to their poor nutritional status, results in decreased or delayed adjuvant systemic therapy, with potential adverse consequences in its efficacy. Among potential solutions, the arrival of new drugs, taxanes and topoisomerase I inhibitors in particular, which have shown encouraging results in metastatic disease, may increase the impact of chemotherapy in a multidisciplinary treatment approach. Pre-treatment with chemotherapy and/or radiation therapy prior to surgery may also be advantageous, averting the problems associated with post-surgical treatment. Such an approach has been shown to be feasible in phase II studies, and is relatively well tolerated by patients. Several carefully designed randomized phase III trials are underway to answer this question.