Effects of Neoadjuvant Intraperitoneal/Systemic Chemotherapy (Bidirectional Chemotherapy) for the Treatment of Patients with Peritoneal Metastasis from Gastric Cancer
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 , which are supposed to be removed completely by peritonectomy. 1. Introduction In the past, peritoneal carcinomatosis (PC) from gastric cancer has been regarded as a terminal stage [1], and the most oncologists regarded as a condition only to be palliated. Preusser et al. published a response rate to chemotherapy of 50% of patients with stage IV gastric cancer, but the response rate was the lowest in patients with PC [2]. Ajani et al. reported that PC was the most common indication of failure of the intensive chemotherapy [3]. Accordingly, surgery alone or chemotherapy alone is not an adequate management for gastric cancer patients with PC. Over the past two decades, a new multimodal treatment called cytoreductive surgery (CRS) [4] plus perioperative chemotherapy (POC) was proposed. POC includes neoadjuvant chemotherapy (NAC), hyperthermic intraperitoneal chemotherapy (HIPEC), and/or early postoperative intraperitoneal chemotherapy (EPIC), which takes the advantage of surgery to reduce the visible tumor burden and POC to eradicate peritoneal micrometastasis and peritoneal free cancer cells (PFCCs) [5]. Survival analyses after CRS plus HIPEC showed that complete cytoreduction is associated with survival improvement [5, 6]. Neoadjuvant chemotherapy is proposed to
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