Abstract
Gastric adenocarcinoma is an aggressive cancer that demonstrates heterogeneous biology depending on patient ethnicity, tumor location, tumor type, and genetic profile. It remains the third leading cause of cancer deaths worldwide and was estimated to result in 782,000 deaths in 2018. Challenges exist in accurately assessing the disease burden, as available radiological staging often underestimates metastatic disease. This diagnostic handicap, along with the poor understanding of the heterogeneous biology of gastric cancer, has hindered the development of effective therapeutic solutions and thus halted improvement in patient outcomes over the last few decades. The management of occult peritoneal disease is complicated, as most patients are understaged by standard imaging studies and therefore thought to have local diseases. In this article, we systematically review recent literature on the limitations that are associated with standard radiographic staging, discuss recent molecular biology advances to better identify and diagnose occult peritoneal disease, and propose possible management strategies to approach this complicated clinical problem.
Highlights
Background and Radiology LimitationsGastric cancer represents a significant global burden, most notable in Asian countries
Two retrospective studies examining patients with limited peritoneal disease or positive cytology demonstrated that treatment with cytoreductive surgery and hyperthermic intraperitoneal therapy in conjugation with perioperative chemotherapy was associated with improved survival [44,45]
A prospective multicenter randomized clinical trial (PERISCOPE II) is currently underway to investigate the utility of radical gastrectomy with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with limited peritoneal disease and/or positive peritoneal cytology who did not progress after initial systemic chemotherapy [46]
Summary
Gastric cancer represents a significant global burden, most notable in Asian countries. Along with higher T and N stage diseases are associated with early peritoneal spread in patients with gastric cancer [12]. The PET/CT scan has been studied in the context of the staging of gastroesophageal cancer and, other than in gastroesophageal junction tumors, it has no role in the assessment of occult peritoneal disease due to the limited resolution of PET scans [17] This is especially true of diffuse-type cancers that have lower baseline SUV compared to intestinal-type cancers [18]. Two retrospective studies examining patients with limited peritoneal disease or positive cytology demonstrated that treatment with cytoreductive surgery and hyperthermic intraperitoneal therapy in conjugation with perioperative chemotherapy was associated with improved survival [44,45]. A prospective multicenter randomized clinical trial (PERISCOPE II) is currently underway to investigate the utility of radical gastrectomy with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with limited peritoneal disease and/or positive peritoneal cytology who did not progress after initial systemic chemotherapy [46]
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