Peritoneal cancer index is a prognostic indicator of survival in advanced gastric cancer with peritoneal carcinomatosis

Objective The peritoneal cancer index(PCI)has been used for the detailed evaluation of the peritoneal spread in tumors of a gynecologic origin and has been found to be a prognostic indicator of survival.The aim of this study was to identify the significance of the PCI in advanced gastric cancer(AGC)with peritoneal carcinomatosis(PC).Methods From 2010 to 2018,a retrospective analysis was carried out of 60 AGC patients with PC,including 21 patients with a PCI≤13 and 39 with a PCI>13.All patients were treated with both surgery and intraoperative peritoneal hyperthermic chemotherapy(IPHC).The performance status(Karnofsky performance status),age,sex,Borromann’s classification,differentiation,depth of invasion,lymph node metastasis,PCI,extent of gastrectomy,extent of lymph node dissection,and residual tumor volume were retrospectively evaluated and correlated to survival.Results The overall 5-year survival rate was 43%and mean survival was(54.47±4.53)months.The favorable clinical prognostic indicators of survival were Borromann’s classification,differentiation,depth of invasion,PCI,and residual tumor volume on univariate analyses(P<0.05).The Cox proportional regression hazard model showed that only the volume of residual tumor and PCI were associated with postoperative survival.The median survival time was 69.76 months for patients with a PCI≤13 and 39.96 months for patients with a PCI>13.There was a significant difference in survival rate between the two group(P=0.004).Postoperative major morbidity and mortality rates were 23.81%and 4.76%in the PCI≤13 group and 43.59%and 5.12%in the PCI>13 group,respectively.Conclusion The peritoneal spread in advanced gastric cancer with peritoneal carcinomatosis can be assessed in detail using the PCI.It is also a significant prognostic factor of survival and is useful in identifying subgroups.

Gastric cancer with peritoneal metastases: Efficiency of standard treatment methods

BACKGROUND Peritoneal metastasis(PM),arising from gastric cancer(GC),is the most common pattern of synchronous and metachronous dissemination and is generally associated with poor prognosis.New therapeutic modalities are being increasingly employed for such patients.AIM To develop more advanced methods,it becomes necessary to study the results of existing standard treatment methods in patients with PM in order to perform a comparative analysis of the strategies.METHODS A retrospective analysis of the efficiency of standard treatment methods(i.e.,palliative chemotherapy,palliative gastrectomy,and the best supportive care)was performed on 200 GC patients with synchronous PM.RESULTS The overall survival(OS)rate in 200 GC patients with PM under standard treatment was 5.4 mo.One-year survival occurred in 18.4%of patients.In multivariate analysis,the survival rate was significantly influenced by the following factors:Presence of extraperitoneal metastases,and stage of PM according to both the Japanese Gastric Cancer Association(JGCA)and the peritoneal cancer index(PCI).The median OS and 1-year survival of patients withР1,P2,and P3(JGCA)carcinomatosis were 9.8 mo,6.7 mo,and 4.0 mo,and 47.2%,18.8%,and 5.1%,respectively.The application of the palliative gastrectomy resulted in an increase in the median OS by up to 17 mo compared to the conservative approach where the value was 8.5 mo(P=0.05)in patients withР1РМ.In patients withР3,palliative chemotherapy increased the OS by up to 5.6 mo compared to the OS of 3.2 mo(P=0.0006)for best supportive care.The median OS and 1-year survival of patients withРCI of 1-6,7-12 and 13+points were 8.5 mo,4.2 mo,and 4.1 mo,and 39.8%,6.7%,and 5.5%,respectively.Palliative gastrectomy increased the median OS to 12.6 mo compared to conservative approach of 8.0 mo(P=0.03)in patients withРCI of 1-6 points.In patients withРCI 13+points,only palliative chemotherapy increased the OS to 6.0 mo compared to the OS of 3.4 mo for best supportive care(P=0.0008).CONCLUSION GC patients with PM are characterized by extremely poor prognoses.Long-term survivors were found in the group with PCI of 1-6 points,and there was no survival difference in groups with PCI 7-12 vs PCI 13+points.Palliative gastrectomy could prove effective in treating patients with early stage PM.The three standard treatment methods are equally effective for moderate stages of PM.In cases with advanced peritoneal carcinomatosis,a significant increase in prognosis was registered only after treatment with palliative chemotherapy.

Combination of docetaxel-carboplatin for adjuvant chemotherapy of epithelial ovarian,primary peritoneal and fallopian tube cancers:a meta-analysis

Objective： The aim of this study was to compare the efficacies and safeties of the combination of docetaxel- carboplatin with the combination of non docetaxel-carboplatin as first-line chemotherapy for advanced epithelial ovarian, pri- mary peritoneal or fallopian tube cancers. Methods： Relevant articles were identified from MEDLINE （1993-2010）, EMBASE （1980-2010）, MEDION, the Cochrane library, Science Citation Index Expanded databases, hand searching of reference lists from primary articles and reviews, conference abstracts and contact with experts in the field. The review included 5 relevant primary studies （1430 women）. Data was extracted for study characteristics and quality. Bivariate random-effect model meta- analysis was used to estimate diagnostic accuracy of the various index tests. A quantitative meta-analysis was carried out by two reviewers based on the inclusion criteria from all available studies. Results： The frequency of the subgroup analysis of toxicity showed that toxicity action of combination of docetaxel-carboplatin was more severe than that of non docetaxel- carboplatin group （OR = 1.33, 95% CI = 1.13-1.56, P = 0.0005）, whereas that of clinical responses was equivalent in com- parison combination of docetaxel-carboplatin with combination of paclitaxel-carboplatin or docetaxel-cisplatin （OR = 1.0, 95% CI = 0.87-1.16, P = 0.95）. There were heterogeneity （X2 = 79.36, P 〈 0.00001） and inconsistency （83.6%） in toxicity analysis among the trials, while neither heterogeneity （x2 = 3.21, P = 0.99） nor inconsistency （F = 0%） in clinical responses among the trials. Conclusion： The safety of combination of docetaxel-carboplatin is less than that of combination of paclitaxel- carboplatin or docetaxel-cisplatin. However, the clinical responses of combination of docetaxel-carboplatin are comparable with combination of paclitaxel-carboplatin or docetaxel-cisplatin.

Peritoneal dissemination of pancreatic cancer caused by endoscopic ultrasound-guided fine needle aspiration:A case report and literature review

BACKGROUND Endoscopic ultrasound-guided fine needle aspiration(EUS-FNA)is a biopsy technique widely used to diagnose pancreatic tumors because of its high sensitivity and specificity.Although needle-tract seeding caused by EUS-FNA has been recently reported,dissemination of pancreatic cancer cells is generally considered to be a rare complication that does not affect patient prognosis.However,the frequency of dissemination and needle-tract seeding appears to have been underestimated.We present a case of peritoneal dissemination of pancreatic cancer due to preoperative EUS-FNA.CASE SUMMARY An 81-year-old man was referred to the Department of Surgery of our hospital in Japan owing to the detection of a pancreatic mass on computed tomography during medical screening.Trans-gastric EUS-FNA revealed that the mass was an adenocarcinoma;hence laparoscopic distal pancreatectomy with lymphadenectomy was performed.No intraoperative peritoneal dissemination and liver metastasis were visually detected,and pelvic lavage cytology was negative for carcinoma cells.The postoperative surgical specimen was negative for carcinoma cells at the dissected margin and the cut end margin;however,pathological findings revealed adenocarcinoma cells on the peritoneal surface proximal to the needle puncture site,and the cells were suspected to be disseminated via EUSFNA.Hence,the patient received adjuvant therapy with S-1(tegafur,gimeracil,and oteracil potassium);however,computed tomography performed 5 mo after surgery revealed liver metastasis and cancerous peritonitis.The patient received palliative therapy and died 8 mo after the operation.CONCLUSION The indications of EUS-FNA should be carefully considered to avoid iatrogenic dissemination,especially for cancers in the pancreatic body or tail.

Comparison of peritoneal free gastric cancer cells' detecting rates between laparoscopically assisted and open radical gastrectomy

Objective： To compare laparoscopic gastrectomy and conventional surgery on the dissemination and seeding of tumor cells. Methods：Intraoperative peritoneal lavage cytologic examination was performed in 65 patients with gastric cancer, during laparoscopic gastrectomy （n = 34） and conventional surgery （n = 31）. Cytology was examined twice, immediately after opening the peritoneal cavity and just before closing the abdomen. Saline was poured into the peritoneal cavity, and 100 ml fluid was retrieved after irrigation. Laparoscopic instruments were lavaged after surgery with 100 ml saline. Carbon dioxide （COz） was derived through the trocar side orifice after pneumoperitoneum during laparoscopic gastrectomy and filtered through 100 ml saline. Cytologic examination of the filtrate was performed after the filtration process. Results： The incidence of positive cytology during laparoscopic surgery was 32.26% in the preoperative lavage and 22.58% in the postoperative lavage. The incidence of positive cytology during conventional surgery was 41.18% before lavage and 26.47% after lavage. Only one positive cytology was detected in the CO2 filtrate gas. The incidence of positive cytology in the lavage of the instruments during laparoscopic surgery was 6.45 %. Conclusion： During gastric laparoscopic surgery, CO2 pneumoperitoneum does not affect tumor cell dissemination and seeding. In this study, laparoscopic techniques used in gastric cancer surgery were not associated with a higher risk for intraperitoneal dissemination of cancer cells than the conventional surgery.

THE RELATIONSHIP BETWEEN SEROSAL TYPES, PATHOLOGICAL CHARACTERISTICS AND FREE CANCER CELLS IN THE PERITONEAL CAVITY OF GASTRIC CANCER PATIENTS

The relationship between free cancer cells and the pathological characteristics of gastric cancer were studied. Of 100 cases of gastric cancer, free cancer cells in the peritoneal cavity were detected in 32 cases (32%). Free cancer cells were most often found in tendonoid (62.2%) and colour diffused (60.0%) serosal types. When the area of serosal invasion was over 20 cm, the positive free cancer cell rate was 56.6% and only 2.5% if below 20 cm. Free cancer cells were related to the depth of cancer infiltration, often found in the S2 and S3 invasion layers, as well as to the pathological characteristics of gastric cancer. Free cancer cells were often seen in infiltrated type cancer, histologically poorly differentiated or undifferentiated adenocarcinoma. and nest or diffused growth types. In patients without peritoneal metastasis (P0), the positive rate was 26.1%. This study proved that Chen's serosal classification is correct and useful in assessing whether the cancer cells have penetrated through the serosa or not during surgery. Different treatments should be used in the cases with different serosal types. In addition to surgery, destruction of free cancer cells should be considered in tendonoid and colour diffused serosal types, so as to prevent peritoneal metastasis.

Hyperthermic intraperitoneal chemotherapy for gastric cancer with peritoneal metastasis:a meta-analysis

Objective:To evaluate the efficacy and safety of hyperthermic intraperitoneal chemotherapy(HIPEC)in the treatment of gastric cancer with peritoneal carcinomatosis.Methods:The relevant clinical controlled studies were retrieved from the databases of PubMed,Cochrane Library,Embase.Risk ratio(RR),as well as the respective 95%confidence interval(CI),was used as a statistical indicator.1-year survival,2-year survival,and safety were analyzed.Results:Two randomized controlled trials(RCTs)and 10 high-quality non-randomized controlled trials(NRCTs)were included,enrolling 837 patients(438 in the HIPEC group and 415 in the control group).Compared with the control group,HIPEC group turned out to be of greater improvement in long-term efficacy:1-year survival rate(1y-os)and 2-year survival rate(2y-os).Subgroup analysis of different treatment modes in NRCTs showed that,in terms of 1-year survival rate,(1)HIPEC combined with cytoreductive surgery(CRS)compared with CRS alone,RR=0.68,95%CI:(0.53,0.85);(2)HIPEC combined with intravenous chemotherapy±CRS versus chemotherapy alone,RR=0.54,95%CI:(0.39,0.74);(3)HIPEC combined with palliative gastrectomy versus palliative gastrectomy,RR=0.37,95%CI:(0.22,0.63).As for safety,there were no significant differences in adverse events between two groups.Conclusion:HIPEC can prolong the survival of gastric cancer patients with peritoneal carcinomatosis,and the incidences of adverse events were not increased.

Diagnostic value of whole-body MRI with diffusion-weighted sequence for detection of peritoneal metastases in colorectal malignancy

Objective：To assess the diagnostic accuracy of whole-body MRI using diffusion-weighted sequence（WB-DWI）to determine the peritoneal cancer index（PCI）in correlation with surgical and histopathological findings.Methods：Twenty-seven patients underwent preoperative WB-MRI,followed by cytoreductive surgery for primary tumors of the appendix（n=15）,colorectum（n=12）,and associated peritoneal disease.A total of 351 regions were retrospectively reviewed.The sensitivity,specificity,and accuracy were calculated at 13 anatomical sites.The WB-DWI PCI and PCI type were compared with surgical and histopathological findings.Results：No statistical difference was found between the WB-DWI PCI and surgical PCI（P=0.574）.WB-DWI correctly predicted the PCI type in 24 of 27 patients with high accuracy（88.9%）,including 10 of 10 patients with small-volume tumor,12 of 14 with moderate-volume tumor,and 2 of 3 with large-volume tumor.WB-DWI correctly depicted tumors in 163 of 203 regions,with 40false-negative and 23 false-positive regions.The overall sensitivity,specificity,and accuracy of WB-DWI for the detection of peritoneal tumors were 80.3%,84.5%,and 82.1%,respectively.For lesions＆lt;0.5 cm in diameter,WB-DWI demonstrated good sensitivity（69.4%）.Conclusions：WB-DWI accurately predicted PCI before surgery in patients undergoing evaluation for cytoreductive surgery.

Primary peritoneal carcinoma metastasizing to breast: a single case report and literature review from clinic to biology

Primary peritoneal carcinoma(PPC) is a type of rare malignant epithelial tumor. Metastasis from PPC to breast has been rarely reported. PPC originates de novo from the peritoneal tissues rather than invasion or metastasis from adjacent or remote organs.PPCs have been implicated in many cases of carcinomas of unknown primary origin. It is similar to ovarian cancer(Ov Ca),because it shares the same common embryonic origin, the coelomic epithelium(mesodermal origin). The mechanism of oncogenesis remains elusive. In this article, we report a rare case of PPC in a patient 10 years after total abdominal hysterectomy and bilateral salpingooophorectomy for uterine leiomyoma, which was widely spread in the abdomen and metastasized to the colon, liver and distant organs including breast. The treatment is similar to that of primary ovarian cancer. We also reviewed the primary peritoneal cancer metastatic to breast and discuss the possible mechanisms and biology of primary peritoneal cancer,using experimental and animal model.

Prediction of peritoneal free cancer cells in gastric cancer patients by golden-angle radial sampling dynamic contrast-enhanced magnetic resonance imaging

Objectiveperitoneal free cancer cells can negatively impact disease progression and patient outcomes in gastric cancer. This study aimed to investigate the feasibility of using golden-angle radial sampling dynamic contrast-enhanced magnetic resonance imaging (GRASP DCE-MRI) to predict the presence of peritoneal free cancer cells in gastric cancer patients.MethodsAll enrolled patients were consecutively divided into analysis and validation groups. Preoperative magnetic resonance imaging (MRI) scans and perfusion were performed in patients with gastric cancer undergoing surgery, and peritoneal lavage specimens were collected for examination. Based on the peritoneal lavage cytology (PLC) results, patients were divided into negative and positive lavage fluid groups. The data collected included clinical and MR information. A nomogram prediction model was constructed to predict the positive rate of peritoneal lavage fluid, and the validity of the model was verified based on data from the verification group.ResultsThere was no statistical difference between the proportion of PLC-positive cases predicted by GRASP DCE-MR and the actual PLC test. MR tumor stage, tumor thickness, and perfusion parameter Tofts-Ketty model volume transfer constant (Ktrans) were independent predictors of positive peritoneal lavage fluid. The nomogram model featured a concordance index (C-index) of 0.785 and 0.742 for the modeling and validation groups, respectively.ConclusionsGRASP DCE-MR could effectively predict peritoneal free cancer cells in gastric cancer patients. The nomogram model constructed using these predictors may help clinicians to better predict the risk of peritoneal free cancer cells being present in gastric cancer patients.

Long-term sustained clinical remission of peritoneal metastatic pancreatic ductal adenocarcinoma after sequential chemoradiation therapy: a case report

Patients with peritoneal metastatic pancreatic ductal adenocarcinoma(pmPDAC)with high-level serum carbohydrate antigens(CAs)always suffer extremely dismal prognosis,with a median survival of several months.Herein,we reported a case of pmPDAC with high serum CAs who had long-term clinical remission with normalization of CAs after chemoradiation.In November 2019,a 64-year-old male patient was admitted to our center with a solid mass measuring 2.8×2.5×2.0 cm in the body of the pancreas near the celiac trunk.Positron emission tomography-computed tomography(PET-CT)revealed an standardized uptake value max(SUVmax)of 4.2.The serum CA 242 level exceeded 150.0 U/mL(normal range:0–20 U/mL),and CA 19-9 was elevated at 975.2 U/mL(normal range:0–34 U/mL).During laparotomy,the tumor was found to encircle the celiac trunk over 180°,with several small peritoneal nodules in the lesser omental cavity.Pathological examination confirmed the diagnosis of pmPDAC.Nextgeneration sequencing revealed RAS G12V,EGFR mutation(-),low tumor mutation burden(TMB),and microsatellite stability(MSS).The patient underwent 6 cycles of the AG regimen(gemcitabine plus nab-paclitaxel),resulting in significant tumor shrinkage and a sharp decline in CAs.Partial remission was achieved.However,due to intolerant neurotoxicity,the AG regimen was discontinued.Subsequently,synchronous oral fluorouracil(S1)and radiation therapy were administered.Five months after radiation treatment,all CAs normalized.Oral S1 was continued for an additional 3 months.Eventually,all anti-cancer drugs were stopped.Computed tomography scans indicated that the tumor still surrounded the celiac trunk and common hepatic artery.After a thorough discussion,a wait-and-see strategy was adopted.Remarkably,32 months after stopping anti-cancer medication,the patient remains in good health,with sustained normalization of CAs.At the last follow-up,he had lived for 50 months,and the normalization of the CAs was sustained for 36 months.Although he still suffers the risk of disease progression,it is a successful case of state-of-the-art chemoradiation for a dismal pmPDAC patient.