Preoperative intraperitoneal chemotherapy for gastric cancer, with special reference to delayed peritoneal complications

Phase II study of weekly paclitaxel by one-hour infusion for advanced gastric cancer

PURPOSE

A phase clinical II trial was conducted to determine the antitumor activity and toxicity of weekly paclitaxel administered to patients with advanced gastric cancer.

METHODS

Sixty-eight patients with advanced gastric cancer and performance status 0-2 were treated with 80 mg/m2 paclitaxel over 1 h following a short course of premedication with dexamethasone, diphenhydramine, and ranitidine administered 30 min prior to the delivery of the paclitaxel. In principle, the treatment was repeated weekly for three courses, followed by a 1-week rest.

RESULTS

Objective responses were observed in 12 of 68 patients (17.6%; 95% confidence interval: 9.5%-28.8%). Two of fourteen (14.2%) patients with no prior chemotherapy and 10 of 54 (18.5%) patients previously treated for metastatic disease developed a partial response. The median therapeutic duration and the median survival time were 96 days and 222 days, respectively. In 212 (85.5%) of 248 total cycles, the original dose of 80 mg/m2 of paclitaxel was administered and was well tolerated. Fourteen of 68 patients (20.1%) experienced grade 3 or 4 neutropenia. Grade 1 or 2 peripheral neuropathy occurred in 10 patients (14.7%).

CONCLUSION

Weekly paclitaxel therapy is an active and safe treatment for advanced gastric cancer.

Postoperative intraperitoneal adhesion pathophysiology

Aside from the normal 'ad integrum' peritoneal regeneration, the postoperative intraperitoneal adhesion formation process may be considered as the pathological part of peritoneal healing following any injury, particularly a surgical one. Despite a large body of clinical and experimental studies, its pathophysiology remains controversial. Moreover, a better understanding of the pathophysiological events and of the medical and surgical factors involved in the adhesion formation process is pivotal in any attempt to control this very frequent phenomenon and its serious consequences.

Digest

Professor Keizo Sugimachi, Editor-in-Chief of Surgery Today (The Japanese Journal of Surgery), has selected from the April, May and June 1995 issues of his journal for this quarter's digest. A digest of BJS for the same perio written by Mr Colin Johnson, European Editor, appears i the Japanese journal.

Chemotherapy in gastric cancer: a review and updated meta-analysis

The five years survival rate for patients with gastric cancer is 15-25%. With the aim of improving survival, chemotherapy has been used in different adjuvant settings. Similarly, but with the aim of improving quality of life and prolonging life, chemotherapy has been used extensively in metastatic disease. In this review we have included studies of systemic and intraperitoneal chemotherapy given before, during or after operation and for advanced disease. A meta-analysis has been made on the 21 randomised studies that used adjuvant systemic chemotherapy postoperatively. A significant survival benefit for the patients treated postoperatively compared with controls was identified (odds ratio (OR) 0.84, 95% confidence interval (CI) 0.74 to 0.96). When western and Asian studies were analysed separately we found no survival benefit for the treated patients in the western groups (OR 0.96 (95 CI 0.83 to 1.12)). Flaws in the conduct of several trials made it difficult to draw firm conclusions, including the exclusion of a small but clinically meaningful survival benefit. Preoperative or neoadjuvant chemotherapy has shown effects in some patients, but no significant benefit was found in the few randomised studies. The few studies that reported intraperitoneal therapy showed no detectable survival benefit either. In patients with advanced disease, four small randomised studies found significantly longer survival in the treated patients. The survival benefit is in the range of 3-9 months, and there were also improvements of the quality of life. Several drug combinations have been tested, however, with no confirmed superiority for a particular regimen.

CONCLUSIONS

Adjuvant chemotherapy cannot be recommended as a routine because of the lack of confirmed beneficial effects. Some patients with advanced disease will have a clinically important benefit from palliative chemotherapy, so this can be recommended for patients who are otherwise in good health.

Prevention of chemotherapy-induced intraperitoneal adhesion formation in rats by icodextrin at a range of concentrations

OBJECTIVE

Two controlled in vivo studies in rats have investigated the effect of icodextrin solution on intraperitoneal chemotherapy-induced adhesion formation. The first study evaluated the effect of three concentrations of icodextrin (4, 15, 20% w/v) in comparison to a phosphate-buffered saline (PBS) control in response to intraperitoneal doxorubicin (n = 40). The second study compared the effect of 4% icodextrin to Ringers' lactate solution (RLS) control in response to intraperitoneal bleomycin (n = 30).

METHODS

Doxorubicin and bleomycin were administered via a continuous pump and as a single bolus (bleomycin only). Doxorubicin 2 ml (23.2 microg/ml) was delivered via pump in conjunction with 20 ml of 4, 15, or 20% icodextrin or PBS (n = 10 per group). In the bleomycin experiments rats received either 2 ml (0.77 U/ml) bleomycin delivered via pump in conjunction with 15 ml 4% icodextrin or RLS, or 0.77 or 0.077 U bleomycin delivered in 15 ml 4% icodextrin or RLS administered as a bolus injection (n = 5 per group). Seven days after the initiation of doxorubicin treatment and 9 days after initiation of bleomycin treatment, the rats were euthanized by CO(2) and the extent of peritoneal adhesion formation was evaluated using an 8-point scoring system.

RESULTS

When icodextrin was administered in conjunction with doxorubicin there was a reduction in the formation of adhesions compared to PBS. Efficacy increased with the concentration of icodextrin used. The lowest dose of bleomycin (0.077 U) caused very few adhesions. Results with bleomycin 0.77 U/ml (pump) and 0.77 U (bolus) showed that 4% icodextrin was significantly more effective than RLS at preventing adhesion formation, irrespective of the dosing regimen.

CONCLUSIONS

These studies suggest that 4% icodextrin may reduce adhesion formation caused by intraperitoneal chemotherapy.