Conversion Surgery with HIPEC for Peritoneal Oligometastatic Gastric Cancer

Abstract

Peritoneal metastases (PM) of gastric cancer (GC) are characterized by a particularly poor prognosis, with median survival time of 6 months, and virtually no 5-year survival reported. Conversion therapy for GC is defined as a surgical treatment aiming at an R0 resection after systemic chemotherapy for tumours that were originally unresectable (or marginally resectable) for technical and/or oncological reasons. The aim of the present study was to evaluate early and late outcomes in GC patients with PM who underwent the cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) after neoadjuvant (conversion) chemotherapy. Thirty patients with stage IV GC underwent CRS plus HIPEC. Severe grade III/IV (Clavien-Dindo classification) complications occurred in 13 (43%) patients. The Comprehensive Complication Index (CCI) ranged from 8.7 to 100 (median, 42.4). In the multivariate survival analysis, ypT2 and P3 (according to the Japanese classification of the PM severity) were favourable and adverse prognostic factors p = 0.031 and o = 0.035, respectively. Estimated 1- and 3-year survival was 73.9% and 36.6%, respectively. The median survival was 19.3 months. Conclusion: Conversion surgery, including extended gastrectomy and multi-organ resections followed by HIPEC performed after systemic chemotherapy therapy for GC with PM is justified in downstaged patients with ypT2 and limited (less than P3) PM.

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“…• staging laparoscopy should be maintained, with informed consent to proceed to gastrectomy if the primary tumor is resectable ○ especially in non-intestinal tumors 45 • for early GC following non-radical endoscopic resection (R1), the definitive radical surgery may be postponed • neoadjuvant (radio-)chemotherapy for resectable cases deferred • upfront gastrectomy preferred if easy resectable with low risk of respiratory complications ○ major GC surgery, as recently defined by experts, 46 only in referral centers with proven low morbidity/ mortality rates, performed by experienced surgeons or under their strict supervision 47 ○ option: HIPEC for limited peritoneal dissemination (CY1; PCI<7; P1/2) should be deferred • adjuvant chemotherapy reserved only for patients with lymph node pN-positive tumors 48 • for bleeding GC, endoscopic management is the first choice option, followed by radiotherapy, and urgent gastrectomy reserved only for life-threatening hemorrhage • perforation of GC with peritonitis should be treated minimally-invasive, with peritoneal lavage and drainage, after no improvement with intravenous broadspectrum antibiotic therapy • for non-resectable or borderline resectable tumors with high risk of complications, primary radical radiochemotherapy should be proposed ○ cases with clinical response might be re-evaluated for resectability in the post-pandemic time ○ otherwise (no tumor/lymph node regression) this radiotherapy should be regarded as definitive treatment • all other loco-regionally advanced (cT4 or cN3) and metastatic (M1; including CY1 or P1-3 following staging laparoscopy) cases should be treated with palliative chemotherapy if performance status is good ○ conversion therapy (surgical resectability reevaluation) postponed to the post-pandemic era 49 Emergency presentation of GC is uncommon, usually associated with an advanced stage and lower rates of operability. The necessity to perform an emergency operation within 24 hours is exceedingly rare.…”

Mixed Type Histology as a Predictive Factor for Esophagojejunostomy Leak in Advanced Gastric Cancer

“…The use of HIPEC in GC has been investigated in both locoregional and metastatic settings [ 34 , 35 ]. Extended gastrectomy combined with peritonectomy and HIPEC may be beneficial to strictly selected patients with oligometastatic peritoneal GC [ 36 , 37 ]. The ongoing phase III RCT’s in the West will determine the potential survival benefit of HIPEC in advanced GC [ 38 , 39 ].…”

“…In our experience, anastomotic leak after gastrectomy plus HIPEC was one of the least common (3%) complications, with median CCI of 42.4, whereas the grade 3–5 complication rate was 47% [ 36 ]. In the present study, among 22 patients who underwent gastrectomy with HIPEC, only one (4.5%) suffered from a postoperative leak.…”

Neoadjuvant systemic and hyperthermic intraperitoneal chemotherapy combined with cytoreductive surgery for gastric cancer patients with limited peritoneal metastasis: a prospective cohort study

“…HIPEC can maintain a high concentration of drugs in the abdominal cavity and enhance the cytotoxicity of chemotherapeutic drugs against tumor cells under the hyperthermia effect [20]. It has been reported that CRS combined with chemotherapy and HIPEC has the potential to control peritoneal metastasis from GC [6,7].…”

“…Recent retrospective studies have reported that the primary tumor and peritoneal metastasis can be well controlled in some patients by comprehensive treatment including systemic and local chemotherapy. Thus, cytoreductive surgery (CRS) of primary tumor and peritoneal metastasis can be achieved and survival time is signi cantly improved [6,7].…”