Prospective Randomized Trial of Early Postoperative Intraperitoneal Chemotherapy as an Adjuvant to Resectable Gastric Cancer

Abstract

ObjectiveSurgeons have postulated on numerous occasions that cancer resection may participate in the dissemination of a malignancy. This randomized trial sought to determine whether a large volume of chemotherapy solution used perioperatively to flood the peritoneal cavity could eliminate microscopic residual disease and thereby improve survival of patients with gastric cancer. Summary Background DataSurgical treatment failures in patients with gastric cancer are confined to the abdomen in most patients. Resection site and peritoneal surface spread, along with liver metastases, are the most common areas of recurrence. Survival and quality of life of patients with gastric cancer would be improved if disease progression at these anatomic sites was reduced. MethodsIn a prospective randomized trial of 248 patients, intraperitoneal mitomycin C on day 1 and intraperitoneal 5-fluorouracil on days 2 through 5 were administered after gastric cancer resection. Patients who were thought to have stage 11 or stage Ill disease were randomized after resection to surgery alone versus surgery plus early postoperative intraperitoneal chemotherapy. After final pathologic examinations, there were 39 patients with stage 1, 50 with stage 11, 95 with stage 111, and 64 with resected stage IV cancer. ResultsThe 5-year survival of the surgery-only group was 29.3%, and the surgery-plus-intraperitoneal chemotherapy group was 38.7% (p = 0.219). In a subset analysis, the patients with stage 1, stage 11, and stage IV disease showed no statistically significant difference in survival. The 5-year survival rate of patients with stage Ill disease who underwent surgery only was 18.4% versus a survival rate of 49.1 % for patients who underwent surgery plus intraperitoneal chemotherapy (p = 0.011). ConclusionsIn a subset analysis, patients with stage Ill gastric cancer have shown a statistically significant improvement in survival when treated with perioperative intraperitoneal chemotherapy. Further studies in patients with gastric cancer with surgically directed chemotherapy are suggested.

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

“…Several studies showed that IPC had a prophylactic benefit against peritoneal recurrence [10,11,15,20]. However, increased risk of postoperative complications was demonstrated by a meta-analysis [15].…”

“…Several studies have reported that IPC was effective as prophylactic and therapeutic treatment of peritoneal dissemination [10][11][12][13][14]. However, many controversies remain unsolved: timing of drug delivery (preoperative, intraoperative, postoperative), use of hyperthermic or normothermic conditions, optimal choice of chemotherapeutic agent for gastric cancer, and efficacy of peritonectomy or cytoreductive surgery with IPC for AGC with macroscopic peritoneal seeding [15].…”

A systematic review of the accuracy and utility of peritoneal cytology in patients with gastric cancer

“…However, some groups suggest that the prognosis of patients with positive IFCCs can be improved through early identification and treatment. Intraperitoneal chemotherapy has been demonstrated to be prophylactic against peritoneal recurrence and to result in improved survival [10,54]. Both neoadjuvant and adjuvant treatment strategies are currently being evaluated.…”

“…To this end, the most recent TNM classification has included IFCC detection as part of the staging process, denoting M1 disease [6]. Traditionally, these patients were considered only for palliation [7]; however, newer strategies have employed more aggressive multimodal therapies in the neoadjuvant [7,8] and adjuvant settings [9][10][11][12] with some evidence of improved outcome [7,8,[10][11][12].…”

Loss of Ep-CAM (CO17-1A) expression predicts survival in patients with gastric cancer

“…Especially within this group there is a need for additional prognostic factors that can be determined preoperatively. Such factors are potentially helpful in identifying patients that might benefit from additional therapeutic modalities, either pre-or postoperatively (Yu et al, 1998;.…”