Peritoneal Recurrence Rate Research Articles

Cirugía de second look más HIPEC en pacientes sin evidencia de recidiva con alto riesgo de desarrollar carcinomatosis tras resección de cáncer colorrectal

IntroductionTo analyze the impact of systematic second-look surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC) performed 1 year after resection of the primary tumor, in asymptomatic patients at high risk of developing peritoneal carcinomatosis (PC). MethodsBetween 2012-2016, 33 patients without any sign of peritoneal recurrence on imaging studies were prospectively included in the study and underwent second-look surgery aimed at treating limited PC earlier and were prospectively recorded. They were selected based on 5 primary tumor-associated criteria: resected minimal synchronous macroscopic PC (n = 10), synchronous ovarian metastases (n = 2), positive peritoneal cytology (n = 2), pT4 primary tumors (n = 15) and perforation (n = 4). ResultsPC was found and treated by cytoreduction plus HIPEC in 10 of the 33 (30.3%) patients, although it was detected in only 2/15 patients of the pT4 subgroup (13.3%). The patients without PC underwent complete abdominal exploration plus HIPEC. Median follow-up was 14.5 months. One patient died postoperatively at day 55. Severe morbidity rate (Clavien-Dindo III-V) was low (15.2%). The 3-year overall survival rate was 93% and the 3-year disease-free survival rate was 33%. Peritoneal recurrences occurred in 4 patients (12.1%), 2 of whom had macroscopic PC discovered at the second-look (20%), while the other 2 patients had no macroscopic PC (8.7%) (P = .04). ConclusionsThe second look + HIPEC strategy in our series of patients at high risk of developing PC, allows its early detection and its treatment in 30.3% of cases, with a very low rate of peritoneal recurrence. It is important to continue evaluating the results to increase the accuracy of the inclusion criteria, especially the pT4 criterion that in this series has a low predictive power for the occurrence of PC.

Systematic Second-look Surgery Plus HIPEC in Patients Without Evidence of Recurrence, at High Risk of Carcinomatosis After Colorectal Cancer Resection

IntroductionTo analyze the impact of systematic second-look surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC) performed 1 year after resection of the primary tumor, in asymptomatic patients at high risk of developing peritoneal carcinomatosis (PC). MethodsBetween 2012 and 2016, 33 patients without any sign of peritoneal recurrence on imaging studies were prospectively included in the study and underwent second-look surgery aimed at treating limited PC earlier and were prospectively recorded. They were selected based on 5 primary tumor-associated criteria: resected minimal synchronous macroscopic PC (n=10), synchronous ovarian metastases (n=2), positive peritoneal cytology (n=2), pT4 primary tumors (n=15) and perforation (n=4). ResultsPC was found and treated by cytoreduction plus HIPEC in 10 of the 33 (30.3%) patients, although it was detected in only 2/15 patients of the pT4 subgroup (13.3%). The patients without PC underwent complete abdominal exploration plus HIPEC. Median follow-up was 14.5 months. One patient died postoperatively at day 55. Severe morbidity rate (Clavien–Dindo III–V) was low (15.2%). The 3-year overall survival rate was 93% and the 3-year disease-free survival rate was 33%. Peritoneal recurrences occurred in 4 patients (12.1%), 2 of whom had macroscopic PC discovered at the second-look (20%), while the other 2 patients had no macroscopic PC (8.7%) (P=.04). ConclusionsThe second look+HIPEC strategy in our series of patients at high risk of developing PC, allows its early detection and its treatment in 30.3% of cases, with a very low rate of peritoneal recurrence. It is important to continue evaluating the results to increase the accuracy of the inclusion criteria, especially the pT4 criterion that in this series has a low predictive power for the occurrence of PC.

High-risk Stage II Colorectal Cancers Carry an Equivalent Risk of Peritoneal Recurrence to Stage III.

Several risk factors for recurrence have been identified in stage II colorectal cancer. However, in contrast to stage III, the benefits of adjuvant chemotherapy for these patients remain controversial. We hypothesized that the different impacts of chemotherapy may be due to different patterns of recurrence between these stages. The aim of this study was to characterize recurrence in high-risk stage II colorectal cancer (CRC) in comparison with stage III. A total of 442 patients with curatively resected stage III and high-risk stage II CRCs were evaluated. The recurrence site and frequency were compared between these stages. The risk factors of recurrence by site were identified using multivariate analyses. During the follow-up (median: 6.4 years), 31% of stage III and 13% of high-risk stage II patients manifested recurrence. Recurrence in the liver, lung, and distant lymph nodes was significantly more frequent in stage III (18%, 12%, 11%) than in high-risk stage II (7%, 6%, 3%). Stage III was independently associated with recurrence in these organs. In contrast, the rate of peritoneal recurrence was 5% in both stages. Clinicians should be aware that high-risk stage II CRC has a similar risk of postoperative recurrence in the peritoneum to Stage III CRC.

Efficacy and safety of surgery combined with intraperitoneal chemotherapy for advanced gastric cancer: a Meta-analysis

Objective To evaluate the efficacy and safety of surgery combined with intraperitoneal chemotherapy for advanced gastric cancer (AGC). Methods The related randomized controlled trials were searched in the following databases such as Cochrane Library, PubMed, Web of Science from database establishment to April 2017. Data extraction and quality assessment by means of NOS were completed by two researchers. The survival rate, recurrence rate, mortality and morbidity were analyzed by RevMan 5.3 software. Results Seventeen literatures which were strictly filtrated from the original 2 383 literatures were included for Meta-analysis and the NOS score was 6-8. A total of 2 302 AGC cases were included to divide for 1 175 undergoing surgery with intraperitoneal chemotherapy and 1 127 undergoing surgery alone. Meta-analysis results showed that compared with surgery alone, surgery with intraperitoneal chemotherapy could improve the 1-year (OR = 1.93, 95% CI 1.41 - 2.66, P < 0.000 1), 2-year (OR= 1.82, 95% CI 1.41- 2.35, P < 0.000 01) and 3 -year (OR= 1.93, 95% CI 1.54- 2.42, P < 0.000 01) survival rate of ACG cases, while the overall mortality was reduced (OR= 0.47, 95% CI 0.34- 0.64, P < 0.000 01). In terms of recurrence rate, the overall (OR= 0.46, 95% CI 0.32- 0.68, P < 0.000 1) and peritoneal (OR= 0.47, 95% CI 0.29- 0.76, P= 0.002) recurrence rates of surgery with intraperitoneal chemotherapy were both lower than those of surgery alone. There were not significantly differences between surgery with intraperitoneal chemotherapy and surgery alone in lymph nodes and liver metastasis rate. However, surgery with intraperitoneal chemotherapy had more high occurrence rates than surgery alone (OR= 1.47, 95% CI 1.16- 1.85, P= 0.001), especially the bone suppression (OR= 3.07, 95% CI 1.70- 5.54, P= 0.002) and bleeding (OR= 3.00, 95% CI 1.09- 8.27, P= 0.03), and there were no differences in other complications. Subgroup results indicated that the overall mortalities were obviously decreased in surgery with intraperitoneal chemotherapy+ MMC (OR= 0.35, 95% CI 0.20- 0.62, P= 0.000 3) or CDDP+ 5-Fu (OR= 0.32, 95% CI 0.17- 0.61, P= 0.000 5) compared with surgery alone. Conclusions Surgery with intraperitoneal chemotherapy can improve survival rate of AGC cases over a period of time and reduce mortality and peritoneal recurrence, but it is likely to cause the morbidities. The safety needs to be improved in the future. Key words: Stomach neoplasms; Surgical procedures, operative; Drug therapy, combination; Randomized controlled study; Meta-analysis; Systemic review

The efficacy of systematic lymph node dissection in advanced epithelial ovarian cancer during interval debulking surgery performed after neoadjuvant chemotherapy.

The therapeutic role of systematic lymph node dissection (LND) remains unclear in advanced epithelial ovarian cancer (EOC), especially during interval debulking surgery (IDS) performed after neoadjuvant chemotherapy (NAC). We analyzed the therapeutic and prognostic roles of systematic LND in advanced EOC patients. Data from consecutive patients with International Federation of Gynecology and Obstetrics (FIGO) stage IIIC-IV disease, who underwent optimal IDS (<1cm) after NAC, were obtained via a retrospective chart review. Patients were classified into a lymph node sampling (LNS; node count <20) group and an LND (node count ≥20) group. Among 133 study patients, 65 and 68 underwent LND and LNS, respectively, during IDS. Overall survival (OS) was significantly better in the LND group than in the LNS group. In subgroup analysis with negative lymphadenopathy on preoperative imaging, progression-free survival (PFS) and OS were significantly better in the LND group than in the LNS group. Follow-up of subsequent recurrences showed significantly lower nodal and peritoneal recurrence rates among patients who underwent LND. Multivariate analysis identified LND as an independent prognostic factor for PFS and OS. Systematic LND may have therapeutic value in advanced EOC patients treated with NAC and IDS.

Traitement des métastases péritonéales des cancers épithéliaux de l’ovaire par thérapie photodynamique. Limites et perspectives

High peritoneal recurrence rate in advanced epithelial ovarian cancer after complete macroscopic cytoreductive surgery and platinum-based chemotherapy, raises the issue of peritoneal microscopic disease management and requires the development of additional locoregional treatment strategies. Photodynamic therapy is an effective treatment already applied in other medical and surgical indications. After administration of a photosensitizer which accumulates in cancer cells, illumination with a light of adequate wavelength may induce photochemical reaction between photosensitizer and tissue oxygen which lead to reactive oxygen species production and cytotoxic phenomenon. Photodynamic therapy's ability to treat superficial lesions disseminated on large area makes it an excellent candidate to insure destruction of microscopic peritoneal metastases in addition to macroscopic cytoreductive surgery in order to decrease peritoneal recurrence rate. Development of intraperitoneal photodynamic therapy has been limited by its poor tolerance related to the lack of specificity of photosensitizers and the location of the metastases in proximity to adjacent intraperitoneal organs. Our aim is to review clinical data concerning intraperitoneal photodynamic therapy and epithelial ovarian cancer to identify the limits of this strategy and to provide solutions which may be applied to solve these barriers and enable safe and effective treatment. Targeted photosensitizers and innovative illumination solutions are mandatory to continue research in this field and to consider the feasibility of clinical trials.

Enhancement of abdominal wall defect repair using allogenic platelet-rich plasma with commercial polyester/cotton fabric (Damour) in a canine model

Platelet-rich plasma (PRP) has an important role in musculoskeletal surgery; however, it has been underutilized for accelerating the healing of abdominal wall defects in veterinary practice. Therefore, the aim of this study was to evaluate the use of commercial polyester/cotton fabric (Damour) as a new composite mesh for the repair of experimentally induced abdominal wall defects in canine models, and to investigate the possible role of PRP for improving such repair and reducing allied complications. For this purpose, abdominal wall defects were created in 24 healthy mongrel dogs and then repaired with mesh alone (control group) or mesh and allogenic PRP (PRP group). Dogs were euthanized after 2 or 4 months for gross examination of implantation site, detection of adhesion score and hernia recurrence. Moreover, tissue samples were collected for histological and gene expression analyses for neovascularization, collagen formation and tissue incorporation. Hernia recurrence was not recorded in PRP-treated dogs that also displayed significantly more neovascularization and less severe adhesion to the underlings (1.08 ± 0.51) in comparison to control group (2.08 ± 0.99). Histological and molecular evaluation confirmed the gross findings that collagen deposition, new vessel formation, and overexpression of angiogenic and myofibroplastic genes (COL1α1, COL3α1, VEGF and TGFβ1) were observed more frequently in the PRP group, at both time points. In conclusion, we found that addition of allogenic PRP to Damour mesh enhanced neovessel formation, and increased tissue deposition and incorporation, with subsequent reduction of peritoneal adhesion and recurrence rate.

Advanced gastric cancer: new perspectives of treatment

The prognosis in patients with advanced gastric cancer with carcinosis remains poor with a median survival of less than one year. High rates of peritoneal recurrence of patients undergoing resection with potentially curative intent are strictly related with lymphatic spread and penetration of the serosa. To increase survival rates, during the last thirty years different strategies about screening and treatment have been tested and proposed. Early detection of occult peritoneal micrometastasis is a base step to reduce local and serosa recurrences and to offer a tailored surgical and neoadjuvant therapeutic treatment. The complete cytoreductive surgery, however, remains the cornerstone of treatment. It could be associated with different combinations of chemotherapy regimens. Adjuvant, neoadjuvant and intraperitoneal chemotherapy have been demonstrated effective in improving the survival. In the last years, a few new molecules have been introduced which enhance the effect of chemotherapy by biologically targeting its objective. Lastly the prevention of macroscopic peritoneal carcinosis in all those patients at high risk due to serosal infiltration by treating them with intraperitoneal chemotherapy has been demonstrated to be one of the future winning approaches. In patients with peritoneal carcionosis, multimodal comprehensive treatment should be mandatory, with a pivotal role of intraperitoneal chemotherapy associate to CC0 cytoreduction. Neoadjuvant chemotherapy followed by cytoreductive surgery and intraperitoneal chemotherapy gave promising results. The new molecules as monoclonal antibodies seem to improve outcomes.

Recursive partition analysis of peritoneal and systemic recurrence in patients with gastric cancer who underwent D2 gastrectomy: Implications for neoadjuvant therapy consideration.

To classify patients with nonmetastatic advanced gastric cancer who underwent D2-gastrectomy into prognostic groups based on peritoneal and systemic recurrence risks. Between 2004 and 2007, 1,090 patients with T3-4 or N+ gastric cancer were identified from our registry. Recurrence rates were estimated using a competing-risk analysis. Different prognostic groups were defined using recursive partitioning analysis (RPA). Median follow-up was 7 years. In the RPA-model for peritoneal recurrence risk, the initial node was split by T stage, indicating that differences between patients with T1-3 and T4 cancer were the greatest. The 5-year peritoneal recurrence rates for patients with T4 (n = 627) and T1-3 (n = 463) disease were 34.3% and 9.1%, respectively. N stage and neural invasion had an additive impact on high-risk patients. The RPA model for systemic relapse incorporated N stage alone and gave two terminal nodes: N0-2 (n = 721) and N3 (n = 369). The 5-year cumulative incidences were 7.7% and 24.5%, respectively. We proposed risk stratification models of peritoneal and systemic recurrence in patients undergoing D2-gastrectomy. This classification could be used for stratification protocols in future studies evaluating adjuvant therapies such as preoperative chemoradiotherapy. J. Surg. Oncol. 2016;114:859-864. © 2016 2016 Wiley Periodicals, Inc.

Prior Tubal Ligation Might Influence Metastatic Spread of Nonendometrioid Endometrial Carcinoma.

ObjectiveThe exfoliation of endometrial carcinoma might intraperitoneally spread through the fallopian tube. We analyzed the influence of prior tubal ligation (TL) in endometrial carcinoma to evaluate whether it can prevent the process and improve patients’ survival.MethodsA total of 562 patients with a diagnosis of endometrial carcinoma at the Peking University People’s Hospital between July 1995 and June 2012 were enrolled in this study. The patients were divided into 2 groups based on the presence or absence of prior TL. International Federation of Gynecology and Obstetrics stage distributions, recurrence rates, survival status, and histopathological findings were compared between the 2 groups. Kaplan-Meier estimates and log-rank tests were used to compare the survival status based on TL in the overall population and stratified by histopathological subtypes and International Federation of Gynecology and Obstetrics stages. Cox models analysis was used to estimate the hazard ratios and 95% confidence intervals for associations between TL and carcinoma-specific mortality. All statistical tests were 2-sided.ResultsOf the 562 patients, 482 (85.7%) had a diagnosis of endometrioid and 80 patients (14.2%) with nonendometrioid carcinoma. Tubal ligation was associated with negative peritoneal cytology in the total population (P = 0.015) and in patients with endometrioid carcinomas (P = 0.02) but not help to reduce carcinoma-specific mortality (P = 0.095 and P = 0.277, respectively). In the nonendometrioid group, TL was not only associated with negative peritoneal cytology (P = 0.004) but also with lower stage (P < 0.001) and lower recurrence rate(P < 0.005), resulting in improved prognosis (P = 0.022). In Cox models analysis adjusted for covariates, TL was inversely associated with lower endometrial carcinoma-specific mortality (hazard ratio, 0.47; 95% confidence interval, 0.14–2.6).ConclusionTubal ligation was associated with lower positive peritoneal cytology, stages, and recurrence rate, and improved prognosis among patients with nonendometrioid carcinoma. Tubal ligation might influence metastatic spread of nonendometrioid endometrial carcinoma. It could also help to reduce positive peritoneal cytology among patients with endometrioid carcinoma, but lacked prognostic significance.

Evaluation of the recurrence pattern of gastric cancer after laparoscopic gastrectomy with D2 lymphadenectomy.

BackgroundThe aim of this study was to analyze the oncological aspects of gastric cancer following laparoscopic gastrectomy with D2 lymphadenectomy (LG-D2).MethodsWe retrospectively evaluated the long-term outcomes of 354 patients who underwent LG-D2 for primary gastric cancer. Recurrence patterns and predictors of peritoneal metastasis were analyzed.ResultsMedian follow-up time was 43.8 months. Five-year overall survival rates for yp/pStages I, II, and III gastric cancer were 93.7, 78.5, and 42.2 %, respectively. Recurrence was observed in 86 patients. Peritoneal metastasis was the most frequent recurrence pattern (n = 51), followed by hepatic metastasis (n = 17). Lymphatic recurrence at distant sites was observed in 10 patients. No locoregional lymph node metastasis or local recurrence was seen. Nine of 51 cases of peritoneal recurrence were detected by probe laparoscopy. Peritoneal recurrence rates were significantly higher in yp/pT4 and yp/pN3 diseases compared with yp/pT ≤ 3 and yp/pN ≤ 2 diseases. Multivariate analyses demonstrated that yp/pT4, yp/pN3, tumor size ≥70 mm, vascular invasion, and undifferentiated tumors were predictors of peritoneal recurrence following LG-D2.ConclusionLong-term outcomes of gastric cancer following LG-D2, including recurrence patterns and predictors of peritoneal metastasis, were comparable to those following open D2 gastrectomy. LG-D2 showed good local control. Probe laparoscopy after LG may be effective in detecting peritoneal recurrence, which is not determined with less invasive examinations, including a CT scan. Future large-scale prospective studies are desirable to evaluate not only surgical but also oncological benefits and safety of LG-D2 for advanced gastric cancer.

Prognostic significance of CEA expression by RT-PCR in peritoneal wash from patients with gastric cancer: result of a 5-year follow-up after curative resection

Objective: Peritoneal recurrence is the most common cause of death after surgery for gastric cancer. Reverse transcriptase polymerase chain reaction (RT-PCR) analysis has been used to detect free cancer cells in peritoneal wash during surgery. This study was conducted to evaluate the prognostic significance of carcinoembrionic antigen (CEA) mRNA detected by RT-PCR in peritoneal wash from patients with gastric cancer after curative resection through a 5-year follow-up.Materials and methods: Peritoneal wash were obtained from 117 patients who underwent curative surgery for gastric cancer. The association between the CEA RT-PCR results, clinicopathological factors, and factors affecting gastric cancer recurrence were evaluated.Results: Among the 117 cases, 38 (32.5%) revealed positive CEA expression. Patients with positive CEA expression showed a higher rate of peritoneal recurrence than those with negative CEA expression (p = 0.047). Depth of invasion, lymph node metastasis, TNM stage, and CEA expression were factors affecting recurrence. CEA expression and depth of invasion were significant prognostic factors in a multivariate analysis, and CEA expression was the most important prognostic factor for recurrence in patients who had undergone curative resection for gastric cancer (hazard ratio: 2.747, p = 0.046).Conclusions: CEA expression in the peritoneal wash was significantly associated with peritoneal recurrence and was the most important prognostic factor for gastric cancer recurrence after curative resection.

Laparoscopic treatment of early-stage endometrial cancer with and without uterine manipulator: Our experience and review of literature

ObjectiveThe aim of this study was to retrospectively compare in a series of 110 patients with early-stage endometrial cancer recurrence rate and surgical outcomes after total laparoscopic (LPS) hysterectomy with lymphadenectomy performed with or without uterine manipulator. Study design110 patients with clinical stage I endometrial cancer were enrolled in a retrospective study and underwent surgical staging comprised of LPS hysterectomy, bilateral salpingo-oophorectomy, and in all cases we performed systematic bilateral pelvic lymphadenectomy with uterine manipulator (Group 1, 55 patients) or without (Group 2, 55 patients). ResultsThe rate of positive cytology and LVSI did not significantly differ between Group 1 and Group 2. 1 patient of the Group 1 had a bladder injury and another patient of Group 2 had an ureteral stricture temporarily treated with a stent. 1 patient of the Group 1 had a bowel occlusion due to a port site hernia under the left 10 mm port, resolved with a bowel resection and an end-to-end anastomosis. In 1 patient of the Group 1 and 2 patients of Group 2 we observed a vaginal cuff dehiscence and in 1 case of Group 2 a pelvic lymphocyst was reported. Postoperative fever was reported in 3 patients of the Group 1 and in 5 patients of group 2 (p = 0.07). ConclusionsOur study confirms that use of uterine manipulator for laparoscopic treatment of endometrial cancer does not increase positive peritoneal citology, LVSI and recurrence rate.

Definition and clinical significance of tumour rupture in gastrointestinal stromal tumours of the small intestine.

Tumour rupture is a risk factor for recurrence of gastrointestinal stromal tumour (GIST). In this study, patterns of recurrence after potential tumour seeding were investigated, and a new definition of tumour rupture, based on major and minor defects of tumour integrity, is proposed. Patients undergoing surgery for non-metastatic small intestinal GIST from 2000 to 2012 were included in the study. Tumour spillage, tumour fracture or piecemeal resection, bowel perforation at the tumour site, blood-tinged ascites, microscopic tumour infiltration into an adjacent organ, and surgical biopsy were defined as major defects of tumour integrity. Peritoneal tumour penetration, iatrogenic peritoneal laceration and microscopically involved margins were defined as minor defects. Seventy-two patients were identified. Median follow-up was 58 (range 7-122) months. Radical surgery was performed in 71 patients. A major defect was recorded in 20 patients, and a minor defect in 21. The 5-year recurrence rate was 64, 29 and 31 per cent in patients with major, minor and no defect respectively (P = 0·001). The hazard ratio (HR) for major defect versus no defect was 3·55 (95 per cent c.i. 1·51 to 8·35). Peritoneal recurrence rates for major, minor and no defect were 52, 25 and 19 per cent respectively (P = 0·002), and the HR for major defect versus no defect was 4·98 (1·69 to 14·68). On multivariable analysis, mitotic index, major defect of tumour integrity, tumour size and age were independently associated with risk of recurrence. Recurrence rates were increased after major, but not minor tumour ruptures.

Extent of Serosal Changes Predicts Peritoneal Recurrence and Poor Prognosis After Curative Surgery for Gastric Cancer.

To investigate whether the width of gastric serosal lesions in advanced gastric cancer patients have a predictive value for peritoneal recurrence and the 5-year survival rate.A total of 1109 patients with advanced noncardia primary gastric adenocarcinoma, who underwent curative gastrectomy between January 1997 and December 2007, were included. Data about tumor size, longitudinal tumor location, resection type, serum albumin concentration, lymphatic/venous invasion, lymph node metastasis status, lesion size, histological and Borrmann type of tumor, as well as the recurrence rate and width of the gastric serosal lesions were collected and analyzed.The peritoneal recurrence rate in patients with gastric serosal lesions ≤3 cm was lower than in patients with gastric serosal lesions >3 cm. Multivariate analyses of the 5-year survival rate variables for all patients revealed significant correlations with serum albumin concentrations (HR 1.382, P = 0.002, 95% CI 1.123–1.701), width of serosa changes (HR 1.377, P = 0.020, 95% CI 1.053–1.802), depth of invasion (HR 1.529, P < 0.001, 95% CI 1.288–1.814), and lymph node metastasis (HR 1.551, P < 0.001, 95% CI 1.420–1.694), whereas for recurrent patients only serum albumin concentrations (HR 2.000, P < 0.001, 95% CI 1.425–2.805), width of serosa changes (HR 1.867, P = 0.002, 95% CI 1.248–2.793), and lymph node metastasis (HR 1.521, P < 0.001, 95% CI 1.249–1.852) correlated with the 5-year survival rate.Gastric serosal lesions >3 cm may indicate a high risk for peritoneal recurrence and serve as additional indicators for preventive postoperative adjuvant chemotherapies in patients with advanced gastric cancer.

Free intraperitoneal tumor cells and outcome in gastric cancer patients: a systematic review and meta-analysis

Despite continuously improving therapies, gastric cancer still shows poor survival in locally advanced stages with local recurrence rates of up to 50% and peritoneal recurrence rates of 17% after curative surgery. We performed a systematic review with meta-analyses to clarify whether positive intraperitoneal cytology (IPC) indicates a high risk of disease recurrence and poor overall survival in gastric cancer. Multiple databases were searched in December 2014 to identify studies on the prognostic significance of positive intraperitoneal cytology in gastric cancer, including: Medline, Biosis, Science Citation Index, Embase, CCMed and publisher databases. Hazard ratios (HR) and associated 95% confidence intervals (CI) were extracted from the identified studies. A meta-analysis was performed using a random-effects model on overall survival, disease-free survival and peritoneal recurrence free survival. A total of 64 studies with a cumulative sample size of 12,883 patients were included. Cytology, quantitative real time polymerase chain reaction (PCR) or both were performed in 35; 21 and 8 studies, respectively. Meta analyses revealed free intraperitoneal tumor cells (FITC) to be associated with poor overall survival in univariate (HR 3.27; 95% CI 2.82 - 3.78]) and multivariate (HR 2.45; 95% CI 2.04 - 2.94) analysis and poor peritoneal recurrence free survival in univariate (4.15; 95% CI 3.10 - 5.57) and multivariate (3.09; 95% CI 2.02 - 4.71) analysis. Subgroup analysis showed this effect to be independent of the detection method, Western or Asian origin or the time of publication. FITC oder positive peritoneal cytology is associated with poor survival and increased peritoneal recurrence in gastric cancer.

The effect of extensive intraoperative peritoneal lavage therapy (EIPL) on stage III B + C and cytology-positive gastric cancer patients.

The aim of this study was to investigate the effects of extensive intraoperative peritoneal lavage (EIPL) therapy on stage III B + C and CY1/P0 gastric cancer patients after potentially curative surgery. The study included 37 patients with CY1/P0 and 23 patients with stage III B + C gastric cancer who were treated with potentially curative gastrectomy and EIPL therapy between March 1995 and May 2013. D2 lymphadenectomy, R0 resection, and EIPL therapy were performed for all cases. Multivariate analysis revealed that male gender (P = 0.01) and lymph node metastasis (P = 0.03) were independent prognostic factors, while positive cytology was not (P = 0.21). There was no significant difference in overall survival rates between the CY1/P0 and stage III B + C groups (P = 0.93). There was also no significant difference in peritoneal recurrence rates, i.e., 13 (35.1%) in the CY1/P0 group and 5 (21.7%) in the stage III B + C group (P = 0.39). EIPL therapy combined with complete resection and sufficient (D2) lymphadenectomy could improve the prognosis of CY1/P0 gastric cancer and, to a similar extent, that of stage III B + C.

A Comparison of Intravenous plus Intraperitoneal Chemotherapy with Intravenous Chemotherapy Alone for the Treatment of Gastric Cancer: A Meta-Analysis.

We aimed to evaluate the effectiveness and safety of intravenous (IV) plus intraperitoneal (IP) chemotherapy compared to intravenous (IV) chemotherapy alone for patients with gastric cancer. Electronic databases were searched up to June 2013. Two authors independently selected studies, extracted data and assessed the quality of included studies. The GRADE System was adopted to rate the level of evidence. Of 392 citations, five RCTs involving 1072 patients were included. Overall, a significant improvement in in one- and three- and five-year survival rate was observed in the IV plus IP chemotherapy group (3 RCTs, n = 360, RR = 1.10, 95% CI 1.04 to1.17), (5 RCTs, n = 953, RR = 1.22, 95% CI 1.11 to1.35) and (3 RCTs, n = 347, RR = 1.42, 95% CI 1.12 to 1.80), respectively. Results supported a significant decrease in the rate of metastases (1 RCT, n = 85, RR = 0.41 95% CI 0.19 to 0.89) and peritoneal recurrence (2 RCTs, n = 297, RR = 0.41, 95% CI 0.26 to 0.62) in the IV plus IP chemotherapy group, however, the incidence of adverse events was increased. For patients with gastric cancer, IV plus IP chemotherapy can improve the overall survival rate and prevent the distant or peritoneal metastases. An increased risk of neutropenia, peripheral edema and neuropathy was observed.

Impact of Preoperative Biliary Drainage on Long-Term Survival in Resected Pancreatic Ductal Adenocarcinoma: A Multicenter Observational Study.

This study aimed to evaluate the impact of preoperative biliary drainage (PBD) on the long-term survival of patients with pancreatic ductal adenocarcinoma (PDAC) who underwent pancreaticoduodenectomy (PD). A multicenter observational study was performed using a common database of patients with resected PDAC from seven high-volume surgical institutions in Japan. Of 932 patients who underwent PD for PDAC, 573 (62 %) underwent PBD, including 407 (44 %) who underwent endoscopic biliary drainage (EBD) and 166 (18 %) who underwent percutaneous transhepatic biliary drainage (PTBD). The patients who did not undergo PBD and those who underwent EBD had a significantly better overall survival than those who underwent PTBD, with median survival times of 25.7 months (P < 0.001), 22.3 months (P = 0.001), and 16.7 months, respectively. Multivariate analysis showed that seven clinicopathologic factors, including the use of PTBD but not EBD, were independently associated with poorer overall survival. Furthermore, patients who underwent PTBD more frequently experienced peritoneal recurrence (23 %) than those who underwent EBD (10 %; P < 0.001) and those who did not undergo PBD (11 %; P = 0.001). Multivariate analysis demonstrated that the independent risk factors for peritoneal recurrence included surgical margin status (P < 0.001) and use of PTBD (P = 0.004). Use of PTBD, but not EBD, was associated with a poorer prognosis, with an increased rate of peritoneal recurrence among patients who underwent PD for PDAC.

Adverse prognostic impact of perioperative allogeneic transfusion on patients with stage II/III gastric cancer.

Allogeneic blood transfusions (BTFs) are sometimes required for radical gastrectomy with regional lymph node dissection for advanced gastric cancer (GC). The prognostic impact of perioperative BTF in GC is controversial. Clinical data were collected retrospectively from 250 consecutive patients who underwent curative gastric resection for stage II/III GC. The prognostic impact of BTF on patient survival was evaluated. Subgroup analysis was performed according to units of blood transfused, timing of BTF, type of gastrectomy, splenectomy, intraoperative estimated blood loss, and year of surgery. Fifty-seven (22.8%) patients underwent perioperative BTF. Patients who received BTF experienced a significantly shorter disease-specific survival after curative surgery, and multivariable analysis identified perioperative BTF as an independent prognostic factor for cancer-related death (hazard ratio, 1.80; 95% confidence interval, 1.05-3.02; p = 0.032). The BTF group experienced significantly lower recurrence-free survival rate and a higher rate of initial peritoneal recurrence. The amount of blood cells transfused had less impact on prognosis. Pre- or postoperative BTF without intraoperative BTF had limited influence on postoperative prognosis. Prognosis of patients was affected by splenectomy. Even when intraoperative blood loss exceeded 800 ml, the prognosis of the non-BTF group was more favorable. The prognostic impact of BTF became less clear after introduction of adjuvant chemotherapy with S-1. BTF was an independent prognostic factor in patients with stage II/III GC after curative gastrectomy. To improve prognosis, BTF should be avoided when possible, particularly during surgery.