Neoadjuvant treatment of gastric cancer with peritoneal dissemination
Introduction
In all studies that address the treatment of carcinomatosis for gastric cancer, complete cytoreduction is a requirement for prolonged survival in the management of this condition.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 For gastric cancer the proportion of patients who receive a complete cytoreduction is small; even in selected patients less than one-third of patients have resection of all visible cancer.7, 8 Neoadjuvant chemotherapy has been proposed as a treatment modality that would increase the proportion of gastric cancer patients with peritoneal seeding who could receive a complete clearing of the cancer.12, 13 Unfortunately, systemic neoadjuvant chemotherapy has never significantly downstaged peritoneal seeding and the presence of carcinomatosis is considered by many a contraindication to the neoadjuvant treatment strategy.
We report a new neoadjuvant treatment modality for gastric cancer with peritoneal seeding; it combines intraperitoneal with systemic chemotherapy in an attempt to eradicate disease on visceral peritoneal surfaces and thereby increase the proportion of patients who may receive complete cytoreduction. It is an attempt to eradicate cancer nodules by multimodality chemotherapy that would enter the cancer nodule from the systemic circulation but also diffuse into the nodule from a chemotherapy solution in the peritoneal cavity. A prospective phase II study was initiated to demonstrate the efficacy of this treatment in the palliation of patients with gastric cancer and carcinomatosis and further explore its toxicities.
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Patients
Patients were enrolled between April, 2001 and December, 2003. PC was diagnosed by biopsy using laparotomy, laparoscopy, or by the cytologic examination of ascites. The eligibility criteria included: (1) histologically or cytologically proven PC from gastric adenocarcinoma; (2) absence of hematogenous metastasis and remote lymph node metastasis; (3) age 65 years or younger; (4) Eastern Clinical Oncology Group scale of performance status 2 or less; (5) adequate bone marrow, liver, cardiac, and
Results
Clinical characteristics of the 61 patients are listed in Table 1. The average age was 45.6 years. All 61 patients had P3 dissemination. Ascites was present in 33 patients. Twenty-eight patients had primary gastric cancer and the remaining 33 patients had recurrent PC.
Prior to NIPS chemotherapy, peritoneal fluid cytology was positive in 39 patients and reverted to negative cytology after treatment in 22. In 33 patients with ascites, all peritoneal fluid disappeared in 12 patients after NIPS
Chemotherapy for PC
In the treatment of cancer arising from gastrointestinal tract, PC has long been considered as a fatal disease, and most surgeons have considered PC as a non-surgical condition. Recently, some investigators have reported limited success with new treatment strategies which include intraperitoneal chemo-hyperthermia, early postoperative intraperitoneal chemotherapy and peritonectomy.3, 4, 5, 6, 7, 8, 9 These studies suggest that intraperitoneal chemotherapy can deliver a high dose intensity into
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