Efficacy of intraperitoneal and intravenous chemotherapy and left upper abdominal evisceration for advanced gastric cancer

Abstract

Background. The study was carried out to evaluate the efficacy of intraperitoneal (IP) and intravenous (IV) chemotherapy, as well as left upper abdominal evisceration (LUAE), for patients with advanced gastric cancer. Methods. We carried out a retrospective study of 348 patients who underwent gastrectomy for advanced gastric carcinoma between 1978 and 1998 at our institution and who had macroscopic type 3 or 4 cancer (Japanese classification) with depth of invasion to the serosal surface, but no liver metastasis or lymph node metastasis around the abdominal aorta. Cumulative survival rates were compared in patients who underwent gastrectomy together with: (1) intraoperative IP chemotherapy alone, (2) postoperative IV chemotherapy alone, (3) both IP and IV, or (4) no chemotherapy. Then patients were stratified according to the presence of peritoneal dissemination (P+) and its absence (P-). In P+ patients, survival was compared between those who received IV chemotherapy and those who did not, and between those who received IP chemotherapy and those who did not. Then, survival was compared between patients with high and low immunosuppressive acidic protein (IAP) levels. Finally, we compared cumulative survival rates in patients (stratified as P+ and P-) who underwent LUAE with cumulative survival rates in those who underwent total gastrectomy combined with resection of the pancreatic body, tail, and spleen (PS). Results. For P- patients, there was no survival advantage with adjuvant IP or IV therapy when compared with surgery alone. For P+ patients, however, there was an improvement in survival when patients received both IP and IV, compared with survival with surgery alone (P < 0.05). In P+ patients aged less than 60 years, there was improvement in survival for those who underwent IP therapy together with surgery (P < 0.05), but not for those who had IV chemotherapy after surgery. When LUAE was examined, there was a survival advantage for this procedure when there was no peritoneal dissemination. Four long-term survivors (surviving for more than 5 years) were identified in our study. Three of the 4 patients were aged less than 60 years, and all 4 had macroscopic type 4 gastric cancers. Conclusion. Although the prognosis for patients with invasive type gastric cancer remains poor, there have been a few long-term survivors, in whom this survival was associated with aggressive combination therapy, including surgery, IP, and IV therapy. P+ patients aged less than 60 years and patients with type 4 gastric cancer may stand to benefit most from such therapy. For P- patients, the role of adjuvant IP or IV therapy continues to be ambiguous, although LUAE in this population may be superior to PS.