Nobuo Matsuki

Safety and Efficacy of Bidirectional Chemotherapy for Treatment of Patients With Peritoneal Dissemination From Gastric Cancer: Selection for Cytoreductive Surgery

There is no standard treatment for peritoneal carcinomatosis (PC) from gastric cancer. New bidirectional chemotherapy (neoadjuvant intraperitoneal‐systemic chemotherapy protocol (NIPS)) was developed. The aim of the present study was to assess the safety and efficacy of NIPS and to show the selection for cytoreductive surgery on PC from gastric cancer. Seventy‐nine patients with PC from gastric cancer were treated with NIPS. A peritoneal port system was introduced into the abdominal cavity. The peritoneal wash cytological examination through a port was done before and after NIPS. The patients were treated with oral TS‐1 twice a daily for 21 days, followed by a 1‐week rest. On day 1, 8, and 15 from the start of oral TS‐1 administration, 30 mg/m2 of Docetaxel and 30 mg/m2 of cisplatinum with 500 ml of saline were introduced into the peritoneal cavity through the port. A median course of oral TS‐1 was 2.1 course and a median time of IP chemoterapy was 5.8. Peritoneal free cancer cells (PFCCs) had been detected in 65 (82.2%) patients before NIPS, and the positive cytology changed to be negative in 41 (63.0%) patients after NIPS. After NIPS, 41 patients underwent laparotomy, and complete cytoreduction was done in 32 (78%) patients. Complete cytoreduction was done in 27 (51.9%) of 52 patients with negative cytology but in only 4 (14.8%) of 27 patients with positive cytology (P < 0.001). Patients with negative cytology after NIPS survived significantly longer than those with positive cytology. The adverse effects after NIPS were mild and there was no treatment‐related deaths. The grade 3/4 hematological adverse effects were found in 2 (2.6%) patients. Grade 3 renal toxicity and port site infection was found in three patients, respectively. NIPS using a port system is a safe and effective treatment for PC. Peritoneal wash cytology through a port system is a good indicator to select the patients to perform cytoreductive surgery. J. Surg. Oncol. 2009;100:311–316.

Randomized clinical trial of D2 and extended paraaortic lymphadenectomy in patients with gastric cancer.

BackgroundThe survival of patients with advanced gastric cancer after D2 dissection is still poor. Asian surgeons have proposed a more radical lymph node dissection, designated as D4 dissection, where paraaortic lymph nodes are removed in combination with D2 dissection. To evaluate the survival benefit of D4 dissection, a multi-institutional randomized trial of D2 vs D4 gastrectomy was conducted.MethodsPatients enrolled in the study had potentially curable gastric adenocarcinoma at an advanced stage. Patients were randomized to undergo either D2 or D4 gastrectomy.ResultsTwo hundred and ninety-three patients were registered and 269 patients were eligible; 135 patients were allocated to the D2 group and 134 to the D4 group. Five-year survival was 52.6% after D2 surgery and 55.0% after D4 gastrectomy. There was no significant difference in survival between the D2 and D4 groups (χ2 = 0.064; P = 0.801). Hospital deaths occurred in 1 patients (0.7%) in the D2 group and 5 in the D4 group D4 gastrectomy is a more risky surgery than D2 dissection. Seven patients (5.2%) in the D2 and 15 (11.2%) in the D4 group died of causes other than gastric cancer recurrence. Sixty-three patients (46.7%) in the D2 group and 52 (38.8%) in the D4 group had disease recurrence.ConclusionProphylactic D4 dissection is not recommended for patients with potentially curable advanced gastric cancer.

Effects of Neoadjuvant Chemotherapy on High-Grade Advanced Gastric Cancers

Twenty-nine cases with high-grade advanced gastric cancer were preoperatively treated with PMUE therapy by a combined use of CDDP 75mg/m2, MMC1Omg/body, Etopocide 150mg/body and UFT 400mg/day. The mean number of courses administered was 2.9 (1–9 courses). The patients received a mean of 1.6 courses (1–4 courses) preoperatively and 1.3 courses postoperatively. The response rate was 62% (18/29), and all the responders were judged as partial response. The resectability rate was 79% and the potentially curable cases were found in 11 cases. The one year survival rate and median survival from initial therapy were 66% and 19.5 months. However, patients with nonresectable tumor showed no survival advantage by the neoadjuvant chemotherapy. These results indicate that the neoadjuvant chemotherapy induces the down staging for the patients with high-grade advanced gastric cancer. In these patients, neoadjuvant chemotherapy and then surgery should be considered.

Surgical treatment for gastric cancer with peritoneal dissemination.

最近10年間の腹膜播種胃癌162症例の外科治療成績を検討した. この間, 手術は胃原発巣切除だけでなく転移巣も可能なかぎり切除し, 化学療法に期待する治療方針をとった.胃原発巣切除は86例に行われ, うち22例が相対非治癒, 64例が絶対非治癒であった. 3ヵ月死亡率は, 相対非治癒切除例9%, 絶対非治癒切除例11%, 非切除例51%で, 非治癒切除術は絶対のみならず相対でも手術死亡は低かった. 1年生存率は相対非治癒切除例41%, 絶対非治癒切除例28%, 非切除例4%で, 切除例とりわけ相対非治癒切除例の予後がよかった. また, 5年生存例は, P2の相対非治癒切除例に2例認めたが, 絶対非治癒切除例と非切除例にはみられなかった.