Peritoneal metastasis is common in gastric cancer. It is difficult to treat and carries a poor prognosis. Intraperitoneal (IP) delivery of chemotherapy can attain a higher drug exposure in the peritoneal cavity but with reduced systemic toxicity. Therefore, we hypothesized that IP paclitaxel with systemic chemotherapy would be clinically beneficial for gastric cancer with peritoneal metastases. Patients with unresectable and/or recurrent gastric adenocarcinoma with peritoneal dissemination and/or positive peritoneal washing cytology were recruited. They underwent eight cycles of IP paclitaxel and systemic XELOX. The primary endpoint was 1-year overall survival rate and secondary endpoints were safety, response rate, and peritoneal cytological response. Patients who subsequently had no distant metastases and two consecutive negative peritoneal cytologies underwent conversion gastrectomy if there was no macroscopic evidence of peritoneal disease at diagnostic laparoscopy. Twenty-two patients were enrolled, receiving at least one cycle of IP paclitaxel at the time of reporting (data cutoff-March 11, 2016). The median number of cycles was 7.5. The median overall survival was 18.8 months, and the 1-year survival rate was 72.2%. One patient died of neutropenic sepsis. Of 19 evaluable patients with measurable disease, 7 (36.8%) achieved PR, 8 (42.1%) achieved SD, and 4 (21.1%) experienced PD. Peritoneal cytology turned negative in 11 of 17 (64.7%) patients. Six patients underwent conversion gastrectomy (4 R0, 2 R1) with a median survival of 21.6 months (range = 8.7-29.9 months). XELOX and IP paclitaxel appears to be an effective regimen in gastric cancer with peritoneal metastases. Conversion gastrectomy may be considered in patients with a favorable response.

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Fig. 3. Completion angiography demonstrates patent popliteal artery with successful exclusion of the pseudoaneurysm and preservation of run-off vessels. Note that the flexion point of the popliteal artery is clearly proximal from the site of injury and stent deployment.

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Metastatic solid pseudopapillary neoplasms of the pancreas are rare, and the stomach is also a rare site for metastases. We present a case of a lady with solid pseudopapillary neoplasm of the pancreas who previously had a distal pancreatectomy but subsequently had multiple hepatic, adrenal peritoneal and nodal metastases. She developed dyspepsia and on oesophagogastroduodenoscopy, was found to have gastric metastases as well. We believe this is the first reported case of metastatic solid pseudopapillary neoplasm of the pancreas to the stomach.