Effects of Neoadjuvant Intraperitoneal/Systemic Chemotherapy (Bidirectional Chemotherapy) for the Treatment of Patients with Peritoneal Metastasis from Gastric Cancer

Abstract

Novel multidisciplinary treatment combined with neoadjuvant intraperitoneal-systemic chemotherapy protocol (NIPS) and peritonectomy was developed. Ninety-six patients were enrolled. Peritoneal wash cytology was performed before and after NIPS through a port system. Patients were treated with 60 mg/m2 of oral S-1 for 21 days, followed by a 1-week rest. On days 1, 8, and 15, 30 mg/m2 of Taxotere and 30 mg/m2 of cisplatin with 500 mL of saline were introduced through the port. NIPS is done 2 cycles before surgery. Three weeks after NIPS, 82 patients were eligible to intend cytoreductive surgery (CRS) by gastrectomy + D2 dissection + periotnectomy to achieve complete cytoreduction. Sixty-eight patients showed positice cytology before NIPS, and the positive cytology results became negative in 47 (69%) patients after NIPS. Complete pathologic response on PC after NIPS was experienced in 30 (36.8%) patients. Stage migration was experienced in 12 patients (14.6%). Complete cytoreduction was achieved in 58 patients (70.7%). By the multivariate analysis, complete cytoreduction and pathologic response became a significantly good survival. However the high morbidity and mortality, stringent patient selection is important. The best indications of the therapy are patients with good pathologic response and PCI ≤ 6, which are supposed to be removed completely by peritonectomy.

Effects of Laparosopic Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Metastasis from Gastric Cancer

“…In our experience, among 44 patients who had been diagnosed as having a PCI ≤ 6 using preoperative CT, the number of patients with an intraoperative PCI ≤ 6 was 29 (66%). In contrast, 12 (41.3%) of the 29 patients who had been diagnosed as having a preoperative PCI ≥ 7 using CT showed an intraoperative PCI ≤ 6 (Yonemura, 2012). Accordingly, patients with a PCI ≤ 6 and who have a significantly favorable prognosis cannot be correctly diagnosed based on preoperative CT.…”

“…The present study demonstrated that the positive cytology changed to be negative in 16 (57.1%) of 28 patients after one session of LHIPEC. Patients with negative cytology after NIPS survived significantly longer than those with positive cytology after cytoreductive surgery combined with perioperative chemotherapy (Yonemura, 2012). LHIPEC .is a useful neoadjuvant therapy for the eradication of PFCCs before cytoreductive surgery.…”

“…Current imaging modalities cannot consistently detect low-volume PM with sizes of 5 -8 mm or less (Koh, Yan, Glenn, & Morris, 2009;Yan, 2008). The diameter of PC in gastric cancer tends to be smaller than that from colorectal and appendiceal cancer, and small PC ≤ 5 mm in diameter were detected using CT with a sensitivity of 11% (Koh et al, 2009;Yan et al, 2008;Yonemura, 2012). The most difficult lesions to detect using CT or MRI are PM on the mesentery of the small bowel with a low depiction rate of 8%.…”

“…Facchiano, Risio, Kianmanesh and Msika (2012) and Valle, Van del Speeten (2009) reported the results of 57 patients who had been treated using LHIPEC, and the complete clinical regression of ascites was found in all the patients. By LHIPEC, PFCCs and the cytokines which may contribute to accelerate the vessel permeability may be washed away from the peritoneal cavity, and ascites may be decreased or disappeared (Yonemura, 2012). Accordingly, LHIPEC is considered as a useful method to control ascites.…”

Different Degrees of Small Bowel Involvement in Peritoneal Carcinomatosis may Predict the Completeness of Cytoreduction Score. Is there a Role for Staging Laparoscopy?

“…Patients undergoing CRS + HIPEC in which surgery achieved complete or near complete cytoreduction (CC-0 or CC-1) were shown to have significantly greater survival benefit over those who did not [25]. Survival analysis studies have shown that patients with PCI scores less than 19 (colorectal) and 10 (gastric) benefit most of CRS + HIPEC, facilitating the use of these scores as general cutoffs for excluding patients from this morbid procedure [26][27][28][29]. Exclusion of patients from definitive resection at laparotomy is undesirable and may impede the timely enrollment of patients into alternate therapies [30].…”