Review of Regional Therapies for Gastric Cancer with Peritoneal Metastases

Abstract

Gastric cancer carries a poor prognosis and is a leading cause of cancer-related mortality worldwide. Patients with gastric cancer who develop peritoneal metastases have an even more dismal prognosis, with median survival time measured in months. Since studies have demonstrated that systemic chemotherapy has poor penetration into the peritoneum, multimodal treatment with intraperitoneal chemotherapy has been proposed for the treatment of peritoneal metastases and has become the foundation for newer therapeutic techniques and clinical trials. These include heated intraperitoneal chemotherapy (HIPEC) with cytoreductive surgery (CRS), which involves the application of heated chemotherapy into the abdomen with or without tumor debulking surgery; normothermic intraperitoneal chemotherapy (NIPEC), in which non-heated chemotherapy can be delivered into the abdomen via a peritoneal port allowing for repeat dosing; and pressurized intraperitoneal aerosolized chemotherapy (PIPAC), a newer technique of pressurized and aerosolized chemotherapy delivered into the abdomen during laparoscopy. Early results with intraperitoneal chemotherapy have shown promise in increasing disease-free and overall survival in select patients. Additionally, there may be a palliative effect of these regional therapies. In this review, we explore and summarize these different intraperitoneal chemotherapy treatment regimens for gastric cancer with peritoneal metastases.

Keywords: HIPEC; PIPAC; cytoreductive surgery; gastric cancer; intraperitoneal chemotherapy; peritoneal carcinomatosis index; peritoneal metastases.

Figure 1

Hyperthermic Intraperitoneal Chemotherapy Perfusion During Cytoreductive Surgery. (A): Closed HIPEC Technique. The midline incision is temporarily closed to create a closed system for the infusion of chemotherapy into the peritoneal cavity. (B): HIPEC Room Set-Up. Operating room set-up during HIPEC, with inflow and outflow peritoneal catheters connected to the perfusion machine.

Figure 2

Intraoperative Administration of Pressurized Intraperitoneal Aerosolized Chemotherapy. (A): PIPAC Room Set-Up. The operating room is cleared during administration of PIPAC. Video and anesthesia monitors face adjacent rooms to ensure patient safety. (B): PIPAC Patient Set-Up. Self-retaining retractors are used to steady the laparoscope camera and Capnopen. Arrows indicate connection to power injector for delivery of chemotherapy. (C): Pressurized Aerosolized Chemotherapy Delivery. Laparoscopic visualization of the Capnopen during PIPAC.