Palliation with a Glimmer of Hope: Management of Resectable Gastric Cancer with Peritoneal Carcinomatosis

In the United States peritoneal seeding from primary gastric cancer occurs in 20-30% of patients. The diagnosis of this advanced disease is usually not provided by clinical studies prior to abdominal exploration. The surgeon is forced to make an intraoperative judgement concerning the risks and benefits of an aggressive management plan versus supportive care. A treatment strategy for this difficult group of patients has been devised and tested in phase II studies. It utilizes extended gastrectomy plus peritonectomy to maximally cytoreduce tumor combined with perioperative intraperitoneal chemotherapy. The perioperative intraperitoneal mitomycin-C chemotherapy is heated to 42 degrees C and manually distributed to provide uniform treatment to all peritoneal surfaces and the resection site. Early postoperative intraperitoneal 5-fluorouracil is gravity distributed. The pharmacologic parameters have been established. Relevant clinical information was collected in this review. Five-year survival of these patients in whom a complete cytoreduction was possible has been observed and a prolonged median survival occurs. Gastrectomy with peritonectomy to eliminate all visible implants combined with perioperative intraperitoneal chemotherapy should be considered in all patients with primary gastric cancer and peritoneal carcinomatosis.