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com/esps/ World J Gastrointest Oncol 2017 March 15; 9(3): 121-128

DOI: 10.4251/wjgo.v9.i3.121 ISSN 1948-5204 (online)

ORIGINAL ARTICLE

Retrospective Cohort Study

Gastric peritoneal carcinomatosis - a retrospective review

Hwee Leong Tan, Claramae Shulyn Chia, Grace Hwei Ching Tan, Su Pin Choo, David Wai-Meng Tai,
Clarinda Wei Ling Chua, Matthew Chau Hsien Ng, Khee Chee Soo, Melissa Ching Ching Teo

Hwee Leong Tan, Claramae Shulyn Chia, Grace Hwei Ching Correspondence to: Melissa Ching Ching Teo, Senior Con­
Tan, Khee Chee Soo, Melissa Ching Ching Teo, Division of sultant/Head, MBBS, MMed (Surg), FRCSEd, FAMS, MPH,
Surgical Oncology, National Cancer Centre Singapore, Singapore Adjunct Associate Professor, Division of Surgical Oncology,
169610, Singapore National Cancer Centre Singapore, 11 Hospital Drive, Singapore
169610, Singapore. [email protected]
Su Pin Choo, David Wai-Meng Tai, Clarinda Wei Ling Chua, Telephone: +65-4368088
Matthew Chau Hsien Ng, Dvision of Medical Oncology, Fax: +65-62256283
National Cancer Centre Singapore, Singapore 169610, Singapore
Received: November 1, 2016
Author contributions: Tan HL conceptualized the study, collected Peer-review started: November 4, 2016
the data, analyzed the data and wrote the manuscript; Chia CS, Tan First decision: November 30, 2016
GHC and Teo MCC conceptualized the study and critically revised Revised: December 13, 2016
the manuscript; Choo SP, Tai DWM, Chua CWL and Ng MCH Accepted: January 2, 2017
assisted in data collection and critically revised the manuscript; Soo Article in press: January 3, 2017
KC critically revised the manuscript. Published online: March 15, 2017

Institutional review board statement: This study involved an

electronic medical record review of the included human study
subjects. Ethics approval was obtained from the Singhealth
Centralised Institutional Review Board. Abstract
AIM
Informed consent statement: No informed consent was deemed To characterize patients with gastric peritoneal carcin­
necessary as majority of the patients we studied have passed omatosis (PC) and their typical clinical and treatment
away at the point of the study. Furthermore, the study involved
course with palliative systemic chemotherapy as the cu­
a retrospective electronic medical record review, with no patient
rrent standard of care.
identifiers included in the results presented, hence bearing minimal
risk to the patients included in the study.
METHODS
Conflict-of-interest statement: There are no conflict-of-interests We performed a retrospective electronic chart review of all
to declare for any of the authors. patients with gastric adenocarcinoma with PC diagnosed
at initial metastatic presentation between January 2010
Data sharing statement: No additional data are available. and December 2014 in a single tertiary referral centre.

Open-Access: This article is an open-access article which was RESULTS

selected by an in-house editor and fully peer-reviewed by external We studied a total of 271 patients with a median age of
reviewers. It is distributed in accordance with the Creative 63.8 years and median follow-up duration of 5.1 mo. The
Commons Attribution Non Commercial (CC BY-NC 4.0) license,
majority (n = 217, 80.1%) had the peritoneum as the
which permits others to distribute, remix, adapt, build upon this
work non-commercially, and license their derivative works on
only site of metastasis at initial presentation. Palliative
different terms, provided the original work is properly cited and systemic chemotherapy was eventually planned for 175
the use is non-commercial. See: http://creativecommons.org/ (64.6%) of our patients at initial presentation, of which
licenses/by-nc/4.0/ 171 were initiated on it. Choice of first-line regime was
in accordance with the National Comprehensive Cancer
Manuscript source: Unsolicited manuscript Network Guidelines for Gastric Cancer Treatment. These

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 Tan HL et al . Gastric peritoneal carcinomatosis

patients underwent a median of one line of chemotherapy, with a median overall survival of approximately four
completing a median of six cycles in total. Chemotherapy months and five-year survival rates of 3%-6%
[1,6,7]
.
disruption due to unplanned hospitalizations occurred in Although palliative systemic chemotherapy has been
114 (66.7%), while cessation of chemotherapy occurred demonstrated in numerous trials to improve survival
in 157 (91.8%), with 42 cessations primarily attributable amongst patients with metastatic gastric cancer to a
to PC-related complications. Patients who had initiation of median of 7.5-12.3 mo
[8-11]
, whether such a benefit
systemic chemotherapy had a significantly better median accrues equally to all sites of gastric cancer metastases
overall survival than those who did not (10.9 mo vs 1.6 is unclear.
mo, P < 0.001). Of patients who had initiation of systemic Peritoneal carcinomatosis (PC) is recognized as an
chemotherapy, those who experienced any disruptions independent poor prognostic factor and is known to
to chemotherapy due to unplanned hospitalizations had have a penchant for causing a wide range of troubling
a significantly worse median overall survival compared to
clinical symptoms including symptomatic ascites, intestinal
those who did not (8.7 mo vs 14.6 mo, P < 0.001). [12]
ob­struction, perforation and obstructive uropathy .
This can result in repeated hospitalizations, therapeutic
CONCLUSION
interventions and rapid deterioration of a patient’s per­
Gastric PC carries a grim prognosis with a clinical course
fraught with disease-related complications which may formance status, which may serve to interrupt and
attenuate any survival benefit which palliative systemic prematurely terminate any planned palliative systemic
chemotherapy may have to offer. As such, investigational chemotherapy regime a patient might be on. There is
use of regional therapies is warranted and required vali­ a paucity of literature on the characteristics of patients
[5]
dation in patients with isolated PC to maximize their with gastric PC , with virtually no studies examining
survival outcomes in the long run. the clinical and treatment course of these patients. The
advent of studies examining the role of cytoreductive
Key words: Peritoneal carcinomatosis; Gastric cancer surgery (CRS) and hyperthermic intraperitoneal chemo­
therapy (HIPEC) for the treatment of gastric PC was
© The Author(s) 2017. Published by Baishideng Publishing borne from the concept of peritoneal metastases being
Group Inc. All rights reserved. a loco-regional disease extension rather than a true
[13-18]
systemic dissemination of gastric cancer . Should
Core tip: We present a retrospective review of the clinical patients with gastric PC be less likely to complete planned
course and treatment outcomes of patients with gastric courses of palliative systemic chemotherapy and hence
peritoneal carcinomatosis. It carries a poor prognosis with perform relatively poorly, it would further bolster the case
a clinical course fraught with disease-related complications for studying CRS and HIPEC for a select group of patients
which disrupts planned systemic palliative chemotherapy with gastric PC to maximize their survival.
in the majority of patients. Such disruptions attenuate the As such, we aim to characterize patients with gastric
benefits of systemic chemotherapy and decrease overall PC and their typical clinical and treatment course to
survival. Patients with isolated peritoneal disease may as
glean a better understanding of how well this subset
such benefit from investigational loco-regional therapies
of metastatic gastric cancer patients are doing with
pending further studies and validation.
palliative systemic chemotherapy as the current standard
of care.
Tan HL, Chia CS, Tan GHC, Choo SP, Tai DWM, Chua CWL,
Ng MCH, Soo KC, Teo MCC. Gastric peritoneal carcinomatosis
MATERIALS AND METHODS
- a retrospective review. World J Gastrointest Oncol 2017; 9(3):
121-128 Available from: URL: http://www.wjgnet.com/1948-5204/ We performed a retrospective review of all patients
full/v9/i3/121.htm DOI: http://dx.doi.org/10.4251/wjgo.v9.i3.121 with metastatic gastric cancer managed at the Na­
tional Cancer Centre Singapore, the largest tertiary
referral centre for cancer treatment locally, over a
5-year period between January 2010 and December
2014. All patients with gastric adenocarcinoma with
INTRODUCTION
peritoneal metastasis diagnosed at initial metastatic
Gastric cancer is the fifth most common cancer across presentation, with or without other concomitant distant
the world, accounting for 723000 deaths per year, the sites of me­tastasis, were included in our study. Patients
[1-3]
third most frequent cause of cancer-related deaths . with is­o­lated positive peritoneal cytology were excluded.
In Singapore, gastric cancer ranks as the seventh and Ele­ctronic records were reviewed for various patient
ninth most common cancers, but accounts for the fo­ characteristics including patient demographics, gastric
urth and fifth most frequent cancer deaths amongst cancer characteristics, treatments administered and
[4]
males and females respectively . The poor prognosis subsequent clinical course through each patient’s follow-
of gastric cancer has in part been attributed to the high up duration.
incidence of advanced disease at presentation, with up All patients included in the study had computed
[5]
to 39% harboring disseminated disease at diagnosis . tomography scans of the thorax, abdomen and pelvis
Metastatic gastric cancer carries a grim prognosis performed for initial staging following the diagnosis of

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 Tan HL et al . Gastric peritoneal carcinomatosis

of data collection.
Table 1 Baseline patient demographics

Characteristic n (%) Statistical analysis

Median age (range) (yr) 63.8 (26.9-89.0)
Statistical analysis was performed using SPSS Statistics
Ethnicity Version 19.0 (Armonk NY: IBM Corp). Continuous and
Chinese 203 (74.9) categorical variables and survival data were analyzed
Indian 13 (4.8) 2
using the Student’s t-test, χ test and Kaplan-Meier
Malay 20 (7.4)
analysis respectively, with a statistical significance level
Others 35 (12.9)
Gender of 5% used.
Male 134 (49.4)
Female 137 (50.6)
ECOG status RESULTS
0 89 (32.8)
1 135 (49.8) Demographics and baseline characteristics
2 28 (10.3) We studied a total of 271 patients with gastric adeno­
3 11 (4.1) carcinoma with PC diagnosed at initial metastatic pre­
4 8 (3.0)
sentation with a median follow-up duration of 5.1 mo (IQR:
ASA score
1 107 (39.5)
2.2-11.7). Patient characteristics are summarized in Table
2 128 (47.2) 1. The median age was 63.8 years (range 26.9-89.0),
3 36 (13.3) with relatively equal gender proportions (49.4% male) and
Comorbidities a predominant Chinese ethnicity (74.9%). The majority
Diabetes mellitus 56 (20.7)
Hypertension 124 (45.8)
of patients had good functional and medical conditions at
Cardiac comorbidities 43 (15.9) the point of diagnosis, with Eastern Cooperative Oncology
Respiratory comorbidities 15 (5.5) Group (ECOG) performance status ratings of 0-1 in 82.6%
Chronic renal impairment 10 (3.7) and American Society of Anaesthesiology (ASA) scores of
Central nervous system comorbidity 19 (7.0)
1-2 in 86.7%.
Previous cancer 27 (10.0)
Cigarette smoking 58 (21.4) The bulk of our patients (n = 258, 95.2%) had
Regular alcohol use 31 (11.4) peritoneal metastasis diagnosed at initial gastric cancer
diagnosis, while the remaining 13 (4.8%) cases of PC
ECOG: Eastern Cooperative Oncology Group; ASA: American Society of were diagnosed as a metastatic recurrence of pre­viously
Anaesthesiology. treated gastric cancer. In our cohort, 217 (80.1%) patients
had the peritoneum as the only site of metastasis
at initial presentation, while 54 (19.9%) had other
gastric adenocarcinoma. Patients without radiological
concomitant distant site(s) of metastasis. Approximately
evidence of metastatic disease then underwent sta­
ging laparoscopy with intra-operative frozen section half of the diagnosis of PC was made radiologically (n
assessment of peritoneal deposits. = 134, 49.4%) while the remainder was made intra-
Palliative systemic chemotherapy was offered as the operatively. Other gastric cancer-related characteristics
standard of care in our institution to all patients with of our cohort are summarized in Table 2. Of note,
metastatic gastric cancer in close discussion with each when comparing patients with peritoneal metastasis
patient. The first-line palliative systemic chemotherapy only to patients with other concomitant distant sites of
regime for each patient was chosen in accordance to metastasis, there was a higher proportion of females
the National Comprehensive Cancer Network Guidelines (53.9% vs 37.0%, P = 0.026) and diffuse histology
for Gastric Cancer Treatment with consideration to (57.1% vs 33.3%, P = 0.002), and a lower proportion of
each patient’s performance status and preferences, HER2/Neu overexpression (16.4% vs 33.3%, P = 0.029).
favoring two to three-agent chemotherapy combinations
over single-agent chemotherapy where possible .
[19]
Palliative systemic chemotherapy
Trastuzumab was additionally offered in cases which were Palliative systemic chemotherapy was offered as standard
positive for Her2/Neu overexpression. Chemotherapy of care in all patients with metastatic gastric cancer in
regime was switched or discontinued based on clinician our institution in close discussion with each patient, with
discretion during the course of follow-up if patients 175 (64.6%) patients eventually planned for systemic
experienced unacceptable levels of toxicity or had clinical chemotherapy following initial metastatic presentation.
evidence of disease progression. Chemotherapy was The subsequent chemotherapy-related clinical course
also put on hold or stopped entirely in the event of acute of these patients is summarized in Figure 1. Expectedly,
deteriorations in patients’ functional and/or medical the baseline functional and medical status of patients
conditions. Other therapeutic interventions including planned for systemic chemotherapy were significantly
surgery, endoscopic therapy and radiotherapy were also better than those who opted for best supportive care
undertaken where clinically indicated. Follow-up duration upfront, with ECOG ratings 0-2 in 98.9% vs 82.3% (P <
of each patient is calculated in months beginning from 0.001) and ASA scores of 1-2 in 92.0% vs 77.1% (P =
initial diagnosis till the last follow-up or death at the point 0.001). Four patients planned for systemic chemotherapy

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 Tan HL et al . Gastric peritoneal carcinomatosis

All patients with gastric peritoneal carcinomatosis (n = 271) Figure 1 Chemotherapy-related clinical course.

Planned for best supportive care upfront (n = 96)

Planned for palliative systemic chemotherapy (n = 175)

Passed away prior to chemotherapy initiation (n = 3)

Defaulted further follow-up to initiate chemotherapy (n = 1)

Initiated on palliative systemic chemotherapy (n = 171)

Cessation of systemic chemotherapy due to the primary reason of

Patient declined continuation of systemic chemotherapy (n = 11)
Medical futility in view of progressive disease (n = 55)
Peritoneal disease-related complications (n = 42)
Unacceptable chemotherapy-related toxicities (n = 4)
Other causes of clinical/functional deterioration (n = 45)

Completed course of chemotherapy (n = 14)

Table 2 Baseline gastric cancer-related characteristics Table 3 First-line chemotherapy regime

Characteristic (n = 271) n (%) Chemotherapy regime (n = 171) n (%)

Presentation of peritoneal metastases Anthracycline + platinum-based agent + nucleotide 13 (7.6)
At initial gastric cancer diagnosis 258 (95.2) analogue
Recurrence of treated gastric cancer 13 (4.8) Examples
Site of metastases epirubicin + cisplatin + 5-fluorouracil
Peritoneal only 217 (80.1) epirubicin + oxaliplatin + 5-fluorouracil
Peritoneal and distant site(s) 54 (19.9) Platinum-based agent + nucleotide analogue 97 (56.7)
Primary gastric cancer location Examples
Gastroesophageal junction 23 (8.5) cisplatin + 5-fluorouracil
Proximal gastric 16 (5.9) oxaliplatin + capecitabine
Gastric body 101 (37.3) cisplatin + S-1
Distal gastric 103 (38.0) Nucleotide analogue monotherapy 30 (17.5)
Linitis plastica 28 (10.3) Examples
Lauren’s classification 5-fluorouracil
Intestinal 129 (47.6) capecitabine
Diffuse 142 (52.4) S-1
c-erb-B2 receptor status (n = 195) FOLFOX (5-fluorouracil + leucovorin + oxaliplatin) 24 (14.0)
Positive 37 (19.0) Other regimes (e.g., Docetaxel + cisplatin + 5-fluorouracil) 7 (4.2)
Negative 158 (81.0)

157 (91.8%) of patients due to a variety of reasons as

did not eventually initiate chemotherapy as three passed delineated in Figure 1. Of note, slightly over a quarter
away prior to chemotherapy initiation due to cancer- (n = 42, 26.8%) of cessations were primarily attri­
related complications while one defaulted further follow- butable to peritoneal disease-related complications.
up for chemotherapy initiation. Eventually, only 14 (8.2%) patients completed their
The most common first-line chemotherapy regimes courses of chemotherapy with subsequent close clinical
utilized in our cohort are summarized in Table 3. Not­ surveillance.
ably, of the 171 patients who eventually initiated
chemotherapy, 138 (80.7%) patients received two or Clinical course and therapeutic interventions
three-agent chemotherapy regimes as first-line the­ Through the course of follow-up, 201 (74.2%) patients
rapy. Our patients underwent a median of one line of required unplanned hospitalizations (median number
chemotherapy (IQR 1-2), completing a median of six of hospitalizations = 2, IQR 1-3) following initial dia­
cycles in total (IQR 3-11). Chemotherapy was disrupted gnosis for various disease and/or treatment-related
in 114 (66.7%) cases due to unplanned hospitalizations, complications including symptomatic ascites, sepsis,
with a median duration of disruption of two weeks (IQR gastric outlet obstruction and gastrointestinal tract ble­
1-2.25) each time. Chemotherapy-related toxicity was eding (Table 4). 242 (89.3%) patients required some
documented in 81 (47.4%) of cases, most commonly form of therapeutic intervention in an outpatient and/or
affecting the gastrointestinal (n = 28, 34.6%), neuro­ inpatient setting including surgery, endoscopic stenting,
logical (n = 23, 28.4%) and hematological (n = 22, feeding tube insertion and radiotherapy (Table 5). Median
27.2%) systems. overall survival of our patient cohort was 8.7 mo (95%CI:
Cessation of systemic chemotherapy occurred in 7.3-10.1) with a trend towards longer survival amongst

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 Tan HL et al . Gastric peritoneal carcinomatosis

Table 4 Reasons requiring unplanned hospitalizations 1.0

P < 0.001

Reason (n = 201) n (%) 0.8

Cumulative survival
Symptomatic ascites 64 (31.8)
Sepsis 64 (31.8) 0.6
Gastric outlet obstruction 60 (29.9)
Palliative systemic chemotherapy
Bleeding GIT 60 (29.9)
Intestinal obstruction 59 (29.4) 0.4
Chemotherapy-related toxicity 23 (11.4)
Obstructive jaundice 17 (8.5)
0.2
Obstructive uropathy 17 (8.5) Best supportive care
Tumour perforation 7 (3.5)
0.0

0 6 12 18 24 30 36 42 48 54 60
Follow up duration (mo)
Table 5 Therapeutic interventions required
Figure 2 Overall survival of patients initiated on palliative systemic
Treatment category Treatment n (%) chemotherapy vs patients who received best supportive care upfront.
Surgery Palliative gastrectomy 32 (36.0)
n = 89 (32.8%) Surgical bypass 46 (51.7)
Open gastrostomy 2 (2.2) 1.0
P < 0.001
Feeding jejunostomy 5 (5.6)
Cytoreductive surgery and 1 (1.1)
0.8
hyperthermic intraperitoneal
Cumulative survival

chemotherapy
Others 3 (3.3) 0.6
Endoscopic intervention Feeding tube insertion only 45 (78.9)
n = 57 (21.0%) Stenting only 8 (14.0)
0.4
Feeding tube insertion and 4 (7.0)
stenting No treatment disruptions
Radiotherapy Radiotherapy to gastric tumour 29 (82.9) 0.2
n = 35 (12.9%) Radiotherapy to other sites 6 (17.1) At least 1 treatment disruption
0.0

0 6 12 18 24 30 36 42 48 54 60
patients with peritoneal metastasis only as compared to Follow up duration (mo)
those with other concomitant distant sites of metastasis
(median survival 8.9 mo vs 7.0 mo, P = 0.061). The Figure 3 Overall survival of patients initiated on palliative systemic chemo­
171 patients who initiated systemic chemotherapy, therapy who had treatment disruptions vs without treatment disruptions.
when compared to the rest of the patients who received
best supportive care upfront, had a significantly better dissemination in other sites of metastasis has likewise
median overall survival of 10.9 mo vs 1.6 mo (P < 0.001) encouraged ventures at examining the benefit of CRS
(Figure 2). Of these patients who initiated systemic and HIPEC in the treatment of PC of other primaries,
chemotherapy, the ones who experienced any disruptions [21]
including gastric cancer . Our understanding of the
to chemotherapy due to unplanned hospitalizations had clinical characteristics of this subgroup of metastatic
a significantly worse median survival compared to those gastric cancer patients with PC and how they fare with
without chemotherapy disruptions (8.7 mo vs 14.6 mo, P the current gold standard of treatment - palliative
< 0.001) (Figure 3). systemic chemotherapy - remains limited, a knowledge
gap we sought to address through this study.
[5]
Gastric PC was reported by Thomassen et al to
DISCUSSION account for a sizeable 35.0% of metastatic disease at
Existing literature on gastric cancer has largely eval­ presentation, with PC as the only site of metastasis
uated metastatic gastric cancer as a homogeneous, in 68.6% of cases, comparable to 80.1% of cases in
un­differentiated entity, with clinical features, prognostic our cohort. It similarly represents 36.0%-45.9% of
factors, treatment outcomes and overall survival exa­ metastatic recurrences after previous curative treat­
[1-3]
mined as a single patient group . In a similar vein, ment for gastric cancer
[22,23]
. Several studies have
treatment for metastatic gastric cancer has also been reported clinical characteristics predictive of peritoneal
predominated by palliative systemic chemotherapy and metastasis at presentation or recurrence including a
[20]
supportive care . There has been a growing interest in younger age, female gender, serosal involvement of
the treatment of PC with the advent of CRS and HIPEC primary tumor and a diffuse histology. We found the
especially in colorectal and appendiceal malignancies. female gender, diffuse histology and absence of HER2/
The idea of peritoneal metastasis representing loco- Neu overexpression to be associated with PC as the sole
[5,23]
regional disease extension as opposed to systemic site of metastatic disease in gastric cancer .

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 Tan HL et al . Gastric peritoneal carcinomatosis

Palliative systemic chemotherapy has been well We report an overall survival of 8.7 mo in our co­
established as the current standard of care for patients hort, comparable to survival outcomes of 7.5-12.3 mo
with metastatic gastric cancer. A recent meta-analysis achieved by patients on systemic chemotherapy in
[8-11]
of 35 trials involving 5726 patients demonstrated that, several trials . Stratified analysis revealed a trend
in terms of overall survival, systemic chemotherapy towards improved survival in patients with isolated
achieves superior outcomes compared to best supportive peritoneal metastasis, in keeping with findings of
[5]
care, and that combination chemotherapy is superior Thomassen et al which reported median survival of 4.6
to single-agent chemotherapy with the trade-off of and 3.3 mo in patients with isolated peritoneal metastasis
[20]
increased incidence of chemotherapy-related toxicity . and peritoneal plus other concomitant distant sites of
Despite the fact that the subgroup of our patient metastasis respectively. This is consistent with proposed
cohort planned for systemic chemotherapy had highly theories of isolated PC as a loco-regional disease ex­
optimal baseline functional and medical statuses (98.9% tension rather than a true systemic dissemination of
with ECOG ratings of 0-2 and 92.0% with ASA scores metastatic disease, which further lends support to the
of 1-2) with a large proportion (80.7%) undergoing investigational use of aggressive loco-regional treatment
two to three-agent combination chemotherapy regimes with CRS and HIPEC in at least selected cases to ma­
upfront, only a mere 14 (8.2%) patients eventually ximize survival outcomes.
completed their chemotherapy regimes with subsequent While we recognize the limitations inherent to the
close clinical surveillance. This could be attributed to retrospective nature of our study, it is, to the best of our
[5]
several reasons. knowledge, the only study after Thomassen et al to
Firstly, a significant proportion of patients who ini­ examine the demographic and disease characteristics
tiated chemotherapy had clinical evidence of pro­gressive of gastric PC, and the first study to examine the clinical
disease in spite of treatment, and even after a trial and treatment course of these patients.
of second, third or fourth-line regimes in a handful of Looking ahead, further studies could examine and
patients, 32.2% eventually opted for supportive care compare the clinical course and outcomes of gastric
in view of treatment futility. The poor response of PC cancer patients with different groups of metastatic sites
to conventional systemic chemotherapy could in part (e.g., peritoneal metastasis vs isolated liver metastasis
be accounted for by the poor penetration of peritoneal vs other distant sites of metastasis). Additionally, del­
deposits by chemotherapeutic agents administered ving further into gastric PC, further work could be put
[24]
systemically . This has spurred efforts at studying the into determining if the extent of peritoneal involvement
efficacy of a combined bidirectional intravenous and affects clinical course and outcomes, which could in turn
intraperitoneal route of chemotherapy administration for help better define a patient subgroup which may best
PC, which has been proven to confer survival benefit in benefit from aggressive loco-regional treatment options.
ovarian cancer, and has been tested in several phase 2
Conclusion
[25,26]
trials for gastric PC with encouraging results .
Secondly, a large proportion of our cohort (74.2%) Gastric PC carries a grim prognosis with a clinical co­
required unplanned hospitalizations due to disease urse fraught with disease-related complications which
and/or treatment-related complications, each of which may attenuate any survival benefit palliative systemic
could significantly accelerate the process of clinical chemotherapy has to offer. As such, investigational use
deterioration. The median number of hospitalizations of regional therapies is warranted and required validation
each of these patients required was 2, for a variety in patients with isolated PC to maximize their survival
of complications including those attributable to PC outcomes in the long run.
including symptomatic ascites, bowel obstruction, obs­
tructive uropathy and obstructive jaundice. Besides
resulting in unforeseen breaks in systemic chemotherapy COMMENTS
COMMENTS
occurring in 66.7% of our patients who underwent Background
chemo­therapy, these acute clinical events also directly Systemic palliative chemotherapy is the current standard of care for all
contributed to significant clinical and functional decline metastatic gastric cancers, including cases with peritoneal carcinomatosis (PC).
necessitating premature cessation of chemotherapy in a Gastric PC is known to cause symptoms requiring repeated hospitalizations
which may interrupt and terminate planned palliative systemic chemotherapy.
quarter of cases (Figure 1). Considering that a sizeable
There exists a paucity of literature examining the clinical course of patients with
proportion of patients who ceased chemotherapy due gastric PC. The authors aimed to characterize patients with gastric PC and their
to other causes of clinical/functional deterioration were typical clinical and treatment course with palliative systemic chemotherapy as
attributable to nosocomial infections contracted during the current standard of care.
admissions for peritoneal disease-related complications,
the inadvertent impact of PC on cessation of systemic Research frontiers
chemotherapy in these patients may indeed be even While systemic palliative chemotherapy has been established as the sta­
ndard of care through several randomized controlled trials demonstrating
greater. The consequent impact on survival outcomes is
survival benefit, the overall prognosis of metastatic gastric cancer remains
evident from our finding of a significantly worse overall poor. Investigational loco-regional treatment options such as intraperitoneal
survival amongst patients on systemic chemotherapy chemotherapy and cytoreductive surgery are currently being studied and
who experienced treatment disruptions (Figure 3). validated as alternative treatment of patients with gastric PC.

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 Tan HL et al . Gastric peritoneal carcinomatosis

Innovations and breakthroughs 11 Glimelius B, Ekström K, Hoffman K, Graf W, Sjödén PO, Haglund
This is, to the best of the knowledge, the only study after Thomassen et al to U, Svensson C, Enander LK, Linné T, Sellström H, Heuman R.
examine the demographic and disease characteristics of gastric PC, and the Randomized comparison between chemotherapy plus best supportive
first study to examine the clinical and treatment course of these patients. care with best supportive care in advanced gastric cancer. Ann Oncol
1997; 8: 163-168 [PMID: 9093725 DOI: 10.1023/A: 1008243606668]
12 Sangisetty SL, Miner TJ. Malignant ascites: A review of prognostic
Applications factors, pathophysiology and therapeutic measures. World J
The authors demonstrated that patients with gastric PC have a grim prognosis, Gastrointest Surg 2012; 4: 87-95 [PMID: 22590662 DOI: 10.4240/
with frequent disease-related complications requiring unplanned hospitalizations wjgs.v4.i4.87]
which disrupt and terminate planned palliative systemic chemotherapy. As such,
13 Gill RS, Al-Adra DP, Nagendran J, Campbell S, Shi X, Haase E,
patients with gastric PC may benefit from investigational loco-regional treatment
Schiller D. Treatment of gastric cancer with peritoneal carcinomatosis
options as an alternative.
by cytoreductive surgery and HIPEC: a systematic review of survival,
mortality, and morbidity. J Surg Oncol 2011; 104: 692-698 [PMID:
Peer-review 21713780 DOI: 10.1002/jso.22017]
The authors present a retrospective study of a cohort of patients with gastric 14 Fujimoto S, Takahashi M, Mutou T, Kobayashi K, Toyosawa T,
cancer and peritoneal metastases treated in a single oncology center. The Isawa E, Sumida M, Ohkubo H. Improved mortality rate of gastric
rationale for the study is important as the prognosis remains poor in this group carcinoma patients with peritoneal carcinomatosis treated with
of patients. The study derives a lot of clinical data describing patients’ baseline intraperitoneal hyperthermic chemoperfusion combined with surgery.
characteristics and their course during palliative therapy. The results are Cancer 1997; 79: 884-891 [PMID: 9041149 DOI: 10.1002/(SICI)109
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15 Yonemura Y, Fujimura T, Nishimura G, FallaR T, Katayama K,
Tsugawa K, Fushida S, Miyazaki I, Tanaka M, Endou Y, Sasaki T.
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Tan HL et al . Gastric peritoneal carcinomatosis

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