Indications for Early Postoperative Intraperitoneal Chemotherapy of Advanced Gastric Cancer: Results of a Prospective Randomized Trial

Abstract

Previous analysis of this prospective randomized trial and meta-analysis of published randomized trials of adjuvant intraperitoneal chemotherapy demonstrated improved survival in patients with advanced gastric cancer. Simple criteria applicable at the time of surgery for patient selection were sought in this analysis. From 1990 to 1995 a series of 248 patients with biopsy-proven gastric cancer were randomized intraoperatively to receive early postoperative intraperitoneal mitomycin C and 5-fluorouracil (125 patients) versus surgery only (123 patients). Gastric resection plus early postoperative intraperitoneal chemotherapy showed improved overall survival compared to surgery only (54% and 38%, respectively; p = 0.0278). There were statistically significant differences in patients with stage III (57% and 23%, respectively; p = 0.0024) and in those with stage IV (28% and 5%, respectively; p = 0.0098) gastric cancer. The improvement in survival rate was statistically significant for the subgroup of patients with gross serosal invasion (52% and 25%, respectively; p = 0.0004) and patients with lymph node metastasis (46% and 22%, respectively; p = 0.0027). The surgeons' impression about lymph node status was unreliable, but assessment of serosal invasion was accurate in 80% of cases. Gross serosal invasion with or without frozen section evaluation of lymph nodes can be used as the major selection criteria for early postoperative intraperitoneal chemotherapy of advanced gastric cancer.

Factors predicting peritoneal recurrence in advanced gastric cancer: implication for adjuvant intraperitoneal chemotherapy

“…Serosal invasion was consistently reported as a significant risk factor for peritoneal recurrence [3,21,22], and some authors have reported that gastric cancer patients with serosal invasion have shown significant improvement in survival when treated with IPC in randomized controlled studies [10,23]. Similar to previous studies, the present study showed that depth of tumor invasion was the most important risk factor regardless of adjuvant chemotherapy administration.…”

Intraperitoneal Chemotherapy as a Multimodal Treatment for Gastric Cancer Patients with Peritoneal Metastasis

“…EPIC had not been performed until Sugarbaker reported this strategy [50], because it was feared that early postoperative chemotherapy might increase the rate of morbidity. Yu et al [17] reported that there was a significant increase in the incidence of intraabdominal bleeding and intraabdominal sepsis in the EPIC group compared with the control group, although most of these complications could be managed conservatively.…”

“…However, it is difficult to detect the metastatic lymph nodes as another source of free cancer cells intraoperatively. Investigators [17] who recommended EPIC advocate that because the pathologic stage can be determined only postoperatively, selective adjuvant IPC should be done postoperatively.…”

“…For these reasons and for convenience, most surgeons perform intraoperatively in Japan. On the other hand, early postoperative intraperitoneal chemotherapy (EPIC), which is performed for 5 -7 days from postoperative day 1 with 5-FU, MMC or cisplatin [17,49], is also performed in western countries and Korea. EPIC had not been performed until Sugarbaker reported this strategy [50], because it was feared that early postoperative chemotherapy might increase the rate of morbidity.…”

“…The efficacy of IPC seems to be affected mainly by the extent of the peritoneal tumor and ascites. Most of positive results were obtained for patients without peritoneal metastasis in an adjuvant setting or for patients with microscopic residual tumor [13][14][15][16][17][18][19][20][21][22].…”