The use of intraperitoneal chemotherapy for gastric malignancies

ABSTRACT

Introduction: Gastric cancer is the fourth/fifth most common malignancy worldwide, with only a quarter of patients achieving a 5-year survival rate. It has been estimated that 15–50% or more of patients have peritoneal disease upon surgical exploration. Until the early 1990s, peritoneal metastasis was considered as terminal stage of the disease; in the late 1990s, selected patients with peritoneal metastasis were recategorized as local disease. Over the past two decades, the treatment of peritoneal involvement has transformed, and cytoreductive surgery plus intraperitoneal therapy have drastically altered the natural course of several malignancies.

Areas covered: We performed a review of studies available on PubMed from 1 January 2014 to 31 July 2019 and the analysis of their reference citations. We describe the most current intraperitoneal chemotherapy opportunities in the treatment of gastric cancer: hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC), laparoscopic hyperthermic intraperitoneal chemotherapy (LHIPEC), neoadjuvant intraperitoneal and systemic chemotherapy (NIPS), LHIPEC + NIPS, extensive intraoperative peritoneal lavage (EIPL), early postoperative intraperitoneal chemotherapy (EPIC), and pressurized intraperitoneal aerosol chemotherapy (PIPAC).

Expert opinion: Comprehensive treatment consisting of CRS combined with perioperative intraperitoneal/systemic chemotherapy can, today, be considered an effective strategy to improve the long-term survival of gastric cancer patients with peritoneal metastasis.

KEYWORDS:

• EPIC
• EPIL
• gastric cancer
• HIPEC
• NIPS

Article highlights

• The poor success of SCT is likely because of the peritoneal-plasma barrier [48 and 49].

• Over the past two decades, the treatment of peritoneal involvement has been transformed and cytoreductive surgery (CRS) plus intraperitoneal (IP) therapy has drastically altered the natural history of several malignancies [1].

• IP infusion of anticancer drugs is intended to enable an increased dose and time of exposure of intra-abdominal tumor cells to anticancer drugs with minimal systemic toxic effects.

• IP administration has been shown to result in a higher drug concentration and longer half-life in the peritoneal cavity compared with intravenous administration, although this is affected by a variety of biophysical parameters, including molecular weight, charge, and solubility [50,51].

• IP chemotherapy includes many options: hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC), laparoscopic hyperthermic intraperitoneal chemotherapy (LHIPEC), neoadjuvant intraperitoneal and systemic chemotherapy (NIPS), LHIPEC + NIPS, extensive intraoperative peritoneal lavage (EIPL), early postoperative intraperitoneal chemotherapy (EPIC), and pressurized intraperitoneal aerosol chemotherapy (PIPAC).

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

A peer reviewer on this manuscript has served as an investigator on the GASTRIPEC trial. Peer reviewers have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper received no funding.