Phase I Trial of Hyperthermic Intraperitoneal Chemoperfusion (HIPEC) with Cisplatin, Mitomycin, and Paclitaxel in Patients with Gastric Adenocarcinoma and Associated Carcinomatosis or Positive Cytology

Cytoreduction and Hyperthermic Intraperitoneal Paclitaxel and Cisplatin for Gastric Cancer with Peritoneal Metastasis

BACKGROUND

Peritoneal metastasis (PM) is the most common site of dissemination of gastric cancer (GC) and is associated with a poor prognosis. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for GC with PM remains controversial due to modest survival and significant morbidity.

METHODS

We conducted a retrospective analysis of patients with GC and PM treated with CRS and HIPEC with cisplatin and paclitaxel for 90 min from June 2019 to December 2022.

RESULTS

Twenty-two patients were included and received a median of 7 (interquartile range [IQR] 4-8) cycles of neoadjuvant systemic therapy. Seventeen patients (77%) underwent a single neoadjuvant laparoscopic HIPEC, and six (27%) patients received chemoradiation. The median Peritoneal Carcinomatosis Index at the time of CRS was 1 (IQR 0-4), and 21 patients (95%) underwent complete cytoreduction (CC-0). An R0 resection was achieved in 20 (91%) patients, and the median length of stay was 5.5 (IQR 4-7.5) days. There were six (27%) 90-day major complications (Clavien-Dindo grade ≥ 3), one (4%) Common Terminology Classification for Adverse Events (CTCAE) grade 4 cytopenia, and one (4%) acute kidney injury. The rate of anastomotic leak (all grades) was 14%, the 30-day readmission rate was 18%, and the 90-day mortality rate was 0%. At a median follow-up of 24 months, the median progression-free survival (PFS) and overall survival (OS) were not reached. The 1-, 2-, and 3-year PFS rates were 65%, 56%, and 40%, respectively, and the 1-, 2-, and 3-year OS rates were 96%, 78%, and 55%, respectively.

CONCLUSIONS

CRS and HIPEC with paclitaxel and cisplatin is well tolerated and is associated with favorable oncologic and perioperative outcomes.

Current Evidence for the Use of HIPEC and Cytoreductive Surgery in Gastric Cancer Metastatic to the Peritoneum

Gastric cancer (GCa) is an aggressive malignancy, representing the third leading cause of cancer mortality worldwide. The poor prognosis of GCa can be associated with the prevalence of peritoneal metastasis (PM). Current international and national GCa treatment guidelines only recommend palliative treatment options for patients with PM. Since the 1980s there have been multiple single arm trials, randomized controlled trials, and metanalysis investigating the use of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with advanced GCa, with or without PM. Results from these studies have been encouraging, with some large-volume centers even incorporating HIPEC into their treatment algorithms for patients with advanced GCa. Additionally, there are several ongoing trials that, when completed, will increase our understanding of the efficacy of CRS & HIPEC in patients with GCa metastatic to the peritoneum. Herein we review the current evidence, ongoing trials, consensus guidelines, and future considerations regarding the use of CRS & HIPEC in patients suffering from GCa with PM.

Hyperthermic Intraperitoneal Chemotherapy May Damage Renal Function and Cause Serum Electrolyte Disturbance: A Retrospective Observational Study

OBJECTIVE

The objective of this study was to evaluate the efficacy of postoperative hyperthermic intraperitoneal chemotherapy (HIPEC) on bone marrow hematopoiesis, liver and kidney function, and serum electrolytes for patients who underwent open radical gastrectomy, and investigate the variation tendency of above indicators.

MATERIALS AND METHODS

The clinical data of 153 patients who underwent open radical gastrectomy were retrospectively analyzed and were divided into HIPEC group (n=83) and control group (n=70). Repeated analysis of variance was used to analyze the variation tendency of bone marrow hematopoiesis, liver and kidney function, and serum electrolytes in the HIPEC and control group, respectively, and then made a comparison between the 2 groups.

RESULTS

There were statistical differences in alanine aminotransferase ( P =0.034), phosphorus ( P+ ) ( P <0.05), potassium (K + ) ( P =0.023), sodium (Na + ) ( P <0.001), and chloride (Cl - ) ( P =0.008) between HIPEC and control group. All outcome indicators changed significantly over time ( P <0.05). No significant difference was found in hemoglobin, white blood cell, platelet, aspartate aminotransferase, total bilirubin, or uric acid between the 2 treatment groups at each time point. On the next day after HIPEC treatment, the levels of blood urea nitrogen, creatinine, and P+ were higher in the HIPEC group, whereas the calcium (Ca + ), magnesium (Mg + ), and K + levels of HIPEC group tended to be lower. However, the effects of HIPEC on alanine aminotransferase, Na + , and Cl - levels needed to be further explored.

CONCLUSIONS

HIPEC treatment after open radical gastrectomy has no significant effect on hematopoietic bone marrow and liver function but may damage renal function; reduce Ca + , Mg + , K + levels; and increase P+ level.

Hyperthermic intraperitoneal chemotherapy for patients with gastric cancer based on laboratory tests is safe: a single Chinese center analysis

Purpose

About 15%—40% of gastric cancer patients have peritoneal metastasis, which leads to poor prognosis. Hyperthermic intraperitoneal chemotherapy (HIPEC) is considered to be an effective treatment for these patients. This study evaluated the efficacy and safety of HIPEC in patients with gastric cancer diagnosed from laboratory tests.

Methods

The clinical and pathological data of 63 patients with gastric cancer who underwent HIPEC in 2017–2021 were prospectively recorded. Fifty-five patients underwent cytoreductive surgery + HIPEC, and eight patients received HIPEC alone. The factors associated with HIPEC safety and efficacy were analyzed. The primary endpoint was overall survival.

Results

The average patient age was 54.84 years and 68.3% of patients were male. Moreover, 79.4% of patients had a peritoneal carcinoma index (PCI) score of ≤ 7 and 61.9% had a completeness of cytoreduction score of 0. Because of peritoneal metastasis, 29 patients (46.03%) were classified as stage IV. Laboratory tests showed no differences in pre-HIPEC blood test results compared to post-HIPEC results after removing the effects of surgery. HIPEC treatment did not cause obvious liver or kidney damage. Serum calcium levels decreased significantly after HIPEC (P = 0.0018). The Karnofsky performance status (KPS) score correlated with the patient’s physical function and improved after HIPEC (P = 0.0045). In coagulation tests, FDP (P < 0.0001) and D-dimer (P < 0.0001) levels increased significantly and CA242 (P = 0.0159), CA724 (P < 0.0001), and CEA (P < 0.0014) levels decreased significantly after HIPEC. Completeness of cytoreduction score was an independent prognostic factor. HIPEC did not show a survival benefit in patients with gastric cancer (P = 0.5505).

Conclusion

HIPEC is a safe treatment for patients with gastric cancer with peritoneal metastasis based on the laboratory tests. However, the efficacy of this treatment on gastric-derived peritoneal metastases requires further confirmation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01795-6.

The cancer-associated fibroblast-related signature predicts prognosis and indicates immune microenvironment infiltration in gastric cancer

Background

Gastric cancer (GC) is one of the most common cancers, with a wide range of symptoms and outcomes. Cancer-associated fibroblasts (CAFs) are newly identified in the tumor microenvironment (TME) and associated with GC progression, prognosis, and treatment response. A novel CAF-associated prognostic model is urgently needed to improve treatment strategies.

Methods

The detailed data of GC samples were downloaded from The Cancer Genome Atlas (TCGA), GSE62254, GSE26253, and GSE84437 datasets, then obtained 18 unique CAF-related genes from the research papers. Eight hundred eight individuals with GC were classified as TCGA or GSE84437 using consensus clustering by the selected CAF-related genes. The difference between the two subtypes revealed in this study was utilized to create the “CAF-related signature score” (CAFS-score) prognostic model and validated with the Gene Expression Omnibus (GEO) database.

Results

We identified two CAF subtypes characterized by high and low CAFS-score in this study. GC patients in the low CAFS-score group had a better OS than those in the high CAFS-score group, and the cancer-related malignant pathways were more active in the high CAFS-score group, compared to the low CAFS-score group. We found that there was more early TNM stage in the low CAFS-score subgroup, while there was more advanced TNM stage in the high CAFS-score subgroup. The expression of TMB was significantly higher in the low CAFS-score subgroup than in the high CAFS-score subgroup. A low CAFS-score was linked to increased microsatellite instability-high (MSI-H), mutation load, and immunological activation. Furthermore, the CAFS-score was linked to the cancer stem cell (CSC) index as well as chemotherapeutic treatment sensitivity. The patients in the high CAFS-score subgroup had significantly higher proportions of monocytes, M2 macrophages, and resting mast cells, while plasma cells and follicular helper T cells were more abundant in the low-risk subgroup. The CAFS-score was also highly correlated with the sensitivity of chemotherapeutic drugs. The low CAFS-score group was more likely to have an immune response and respond to immunotherapy. We developed a nomogram to improve the CAFS-clinical score’s usefulness.

Conclusion

The CAFS-score may have a significant role in the TME, clinicopathological characteristics, prognosis, CSC, MSI, and drug sensitivity, according to our investigation of CAFs in GC. We also analyzed the value of the CAFS-score in immune response and immunotherapy. This work provides a foundation for improving prognosis and responding to immunotherapy in patients with GC.

Intraperitoneal therapy for gastric cancer peritoneal carcinomatosis

INTRODUCTION

Gastric adenocarcinoma (GAC) is one of the most aggressive malignancies worldwide and has a poor prognosis. Multidisciplinary therapies are used in its treatment, but the prognosis for GAC patients with peritoneal metastases (PM) remains poor and there is no effective established approach.

AREAS COVERED

This review summarizes the results of recent clinical studies and recent advances in the management, including surgery, chemotherapy, targeted therapy, and immunotherapy. In this review, keywords were searched in combination with 'peritoneal carcinomatosis' and 'gastric cancer' in PubMed, and then studies that evaluated peritoneal carcinomatosis associated with gastric cancer were identified through reading them. Several studies were quoted at second hand. Despite recent advances in therapeutic approaches such as systemic chemotherapy, immunotherapy, intraperitoneal chemotherapy, debulking surgery, thermal hyperthermic intraperitoneal chemotherapy, pressurized intraperitoneal aerosol chemotherapy, immunotherapy, and best supportive therapy, further studies are necessary. This review also summarizes molecular biology of GAC patients with PM.

EXPERT OPINION

Each modality is advancing and some have shown therapeutic effects, but none have become standard treatments that exhibit remarkable effects. To improve the prognosis of GAC patients with PM, large-scale clinical trials and further basic research are required.

Prophylactic hyperthermic intraperitoneal chemotherapy may benefit the long-term survival of patients after radical gastric cancer surgery

Hyperthermic intraperitoneal chemotherapy (HIPEC) has been proven to improve the survival rate of gastric cancer and reduce peritoneal recurrence. We aimed to evaluate the effectiveness and safety of prophylactic HIPEC after radical gastric cancer surgery in this study. Researchers searched for studies published in PubMed, Embase, Web of science, Scopus, Cochrane, Clinical key databases and Microsoft Academic databases to identify studies that examine the impact of prophylactic HIPEC on the survival, recurrence and adverse events of patients undergoing radical gastric cancer surgery. RevMan 5.3 was used to analyze the results and risk of bias. The PROSERO registration number is CRD42021262016. This meta-analysis included 22 studies with a total of 2097 patients, 12 of which are RCTs. The results showed that the 1-, 3- and 5-year overall survival rate was significantly favorable to HIPEC (OR 5.10, 2.07, 1.96 respectively). Compared with the control group, the overall recurrence rate and peritoneal recurrence rate of the HIPEC group were significantly lower (OR 0.41, 0.24 respectively). Significantly favorable to the control group in terms of renal dysfunction and pulmonary dysfunction complications (OR 2.44, 6.03 respectively). Regarding the causes of death due to postoperative recurrence: liver recurrence, lymph node and local recurrence and peritoneal recurrence, the overall effect is not significantly different (OR 0.81, 1.19, 0.37 respectively). 1-, 3- and 5-year overall survival follow-up may be incremented by the prophylactic HIPEC, and which reduce the overall recurrence rate and peritoneal recurrence rate. HIPEC may have high-risk of pulmonary dysfunction and renal dysfunction complications. No difference has been found in the deaths due to recurrence after surgery.

Elemene-containing hyperthermic intraperitoneal chemotherapy combined with chemotherapy for elderly patients with peritoneal metastatic advanced gastric cancer

BACKGROUND

Almost all elderly patients with peritoneal metastatic gastric cancer (PGC) are unlikely to tolerate cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) and adjuvant chemotherapy. However, determining how to optimize the treatment strategy for such patients has always been a clinical problem. Both HIPEC and palliative adjuvant chemotherapy can benefit patients with PGC. Therefore, optimizing HIPEC and chemotherapy regimens has potential clinical value in reducing side effects, and improving treatment tolerance and clinical effectiveness.

AIM

To explore the effect of HIPEC containing elemene, which is an anti-cancer component extracted in traditional Chinese herbal medicine, combined with reduced capecitabine and oxaliplatin (CapeOx) chemotherapy regimens, in elderly patients with PGC.

METHODS

In the present study, 39 of 52 elderly PGC patients were included and assigned to different HIPEC treatment groups [lobaplatin group (group L) and mixed group (group M)] for analysis. Lobaplatin was used for all three HIPECs in group L. In group M, lobaplatin was used in the middle of the three HIPECs, and elemene was used for the first and third HIPEC. After HIPEC, patients received CapeOx chemotherapy. The incidence of complications (abdominal infection, lung infection, and urinary tract infection), myelosuppression, immune function (CD4/CD8 ratio), average length of hospital stay, and prognosis were compared between these two groups.

RESULTS

There was no significant difference in the incidence of complications between the two groups during hospitalization (P > 0.05). Compared to patients in group M, patients in group L exhibited severe myelosuppression (P = 0.027) and increased length of hospital stay (P = 0.045). However, no overall survival benefit was observed in group M. Furthermore, the immune function of patients in group M was less affected (P < 0.001), when compared to that of patients in group L. The multivariate analysis suggested that the cycles of chemotherapy after perfusion significantly affected the prognosis of patients in both groups.

CONCLUSION

Compared to the lobaplatin-based HIPEC regimen, the administration of elemene reduced the myelosuppression incidence in elderly PGC patients. The present study sheds light on the implementation of this therapeutic strategy for this set of patients.

Laparoscopic Heated Intraperitoneal Chemotherapy in the Treatment of Carcinomatosis of Gastric Adenocarcinoma Origin

The use of heated intraperitoneal chemotherapy (HIPEC) in conjunction with cytoreductive surgery has been gaining increasing traction in treating gastric adenocarcinoma with metastasis to the peritoneum in recent years. The addition of laparoscopic HIPEC (LS-HIPEC) to these treatment algorithms has increased the flexibility and adaptability of HIPEC integrating into treatment sequencing, allowing for iterative protocols of LS-HIPEC prior to cytoreduction as neoadjuvant treatment, as well as in the palliation of patients with unresectable disease and uncontrolled ascites. As the use of HIPEC in gastric adenocarcinoma continues to be refined, LS-HIPEC algorithms should continue to be considered and utilized both in curative treatment algorithms as well as in patients in the palliative setting. Given that LS-HIPEC remains a relatively nascent treatment modality, we advocate for its use in the setting of a clinical trial when feasible.

Neoadjuvant intraperitoneal chemotherapy for advanced stage gastric cancer (Review)

Gastric cancer remains one of the most lethal malignancies especially when diagnosed in advanced stages of the disease; most often patients diagnosed later during the progression of their disease will present a certain degree of peritoneal contamination such as positive peritoneal cytology or peritoneal metastatic nodules. In such cases most often they then progress to peritoneal carcinomatosis and succumb to the disease within one year. In order to increase the lifespan in such cases multiple therapeutic strategies have been proposed such as radical surgery and intraperitoneal heated chemotherapy or direct intraperitoneal chemotherapy followed by radical surgery. To date, the benefits of intraperitoneal heated chemotherapy at the time of resection have been widely investigated; however the method is still associated with increased rates of perioperative complications. Therefore, attention was focused on investigating the benefits of such procedures as neoadjuvant therapies followed by radical surgery. The aim of the present review was to examine the most efficient therapeutic strategies in advanced-stage gastric cancer such as neoadjuvant laparoscopic heated intraperitoneal chemotherapy, perioperative heated intraperitoneal chemotherapy and neoadjuvant systemic and peritoneal chemotherapy.

Laparoscopic HIPEC for Low-Volume Peritoneal Metastasis in Gastric and Gastroesophageal Adenocarcinoma

BACKGROUND

We seek to determine whether laparoscopic hyperthermic intraperitoneal chemoperfusion (LS-HIPEC) improves overall survival (OS) in patients with gastric and gastroesophageal adenocarcinoma and low-volume peritoneal metastasis compared with standard of care treatment.

PATIENTS AND METHODS

We reviewed data from a prospectively maintained database of patients with gastric and gastroesophageal adenocarcinoma to identify patients with radiologically occult carcinomatosis or positive peritoneal cytology, no evidence of distant metastasis, and without disease progression during initial chemotherapy or observation. Univariate and multivariable analyses were performed to evaluate the impact of LS-HIPEC on OS.

RESULTS

We identified 25 patients who underwent LS-HIPEC and 27 treated with a standard of care approach due to patient (33.3%) or provider (51.9%) preference or financial limitations/lack of insurance coverage (14.8%). Resection was ultimately performed in 28% of LS-HIPEC patients and no standard care patients. At a median follow-up of 18.9 months, median OS was 24.7 (IQR 20.8-34.2) months in LS-HIPEC patients and 21.3 (IQR 12.3-23.1) months in standard care patients (p = 0.08). Three-year OS in the LS-HIPEC group was 19.1%, compared with 9.6% (p = 0.08). Patients who underwent resection had a median OS of 25.3 (IQR 22.6-47.1) months compared with 21.3 months in standard care patients (p = 0.05).

CONCLUSIONS

Neoadjuvant LS-HIPEC for the treatment of low-volume peritoneal disease in gastric and gastroesophageal cancer patients did not significantly improve OS compared with standard care. Multiinstitutional studies are necessary to further elucidate the benefit of LS-HIPEC for this patient population.

Factors Associated with Resection and Survival After Laparoscopic HIPEC for Peritoneal Gastric Cancer Metastasis

PURPOSE

Although laparoscopic hyperthermic intraperitoneal chemotherapy (LS-HIPEC) has been proven safe in patients with gastric adenocarcinoma and carcinomatosis or positive cytology, patient selection criteria remain unclear. Thus, we perform a retrospective analysis to identify factors associated with improved survival and resection rates.

PATIENTS AND METHODS

Data for all patients undergoing LS-HIPEC for stage IV gastric adenocarcinoma between June 2014 and November 2018 were collected prospectively and analyzed for associations with survival and resection using uni- and multivariate logistic regression, Cox proportional hazards models, and Kaplan-Meier survival functions.

RESULTS

Of 70 patients who underwent LS-HIPEC, 43 (61%) received two drugs (mitomycin C and cisplatin), and 27 (39%) received three drugs (mitomycin C, cisplatin, and paclitaxel). The two groups' demographic and oncologic differences were not significant, although the three-drug group had a significantly lower rate of radiation therapy use (58% vs. 15%; p < 0.01). Univariate analysis revealed that poor differentiation [Cox hazard ratio (HR) 2.75; 95% confidence interval (CI) 1.34-5.63; p < 0.01], gross carcinomatosis (HR 3.10; 95% CI 1.52-6.30; p = 0.03), and ascites (HR 3.43; 95% CI 1.88-6.26; p < 0.01) were associated with shorter median survival. Gastrectomy was associated with improved overall survival (HR 0.32; 95% CI 0.15-0.70; p < 0.01). The resection rate of the 45 patients without ascites (38%) was significantly higher than that of the 25 patients with ascites (0%; p < 0.01).

CONCLUSIONS

Our findings identify ascites as a significant prognostic factor for gastric cancer patients with peritoneal metastases undergoing LS-HIPEC. Our findings can be used to help identify patients who are unlikely to proceed to resection after LS-HIPEC and are good candidates for novel therapeutic approaches or clinical trials.