HIPEC and CRS in peritoneal metastatic gastric cancer - who really benefits?

Gastric cancer with the presence of peritoneal metastases (pmgc) is associated with a very poor prognosis. Despite the wide utilization and promising results of the multimodal treatment regimens including cytoreductive surgery (CRS) and a subsequent hyperthermic intraperitoneal chemotherapy (HIPEC), it is still not fully understood which patient group is suitable for this treatment.

Twenty-six patients (median age 53 years, range 39-71) were scheduled for three cycles of neoadjuvant systemic chemotherapy using bi-weekly FLOT-protocol followed by CRS + HIPEC. After this treatment 3 additional cycles of FLOT were given. During HIPEC Oxaliplatin was applied in a dosage of 200 mg/m² and Docetaxel in a dosage of 80 mg/m².

All patients underwent the standardized multimodal treatment including FLOT, CRS and HIPEC. This treatment resulted in an overall survival (OS) of 17 months in comparison to 6 months as the outcome of the classic treatments. Regression analysis demonstrated a Peritoneal Cancer Index (PCI) ≥ 12 as a negative factor for survival. Furthermore, we could see a worse prognosis by a higher temperature (>41,4 °C) of the chemotherapy used for the HIPEC. In consideration of the gender, the histomorphology and the Laurén-classification, we could develop a precise score to define the patient group which will benefit from this multimodal treatment with a prognosis improvement of 24 months.

Neoadjuvant chemotherapy using the FLOT-protocol followed by CRS + HIPEC seems to be associated with prolonged OS in patients with peritoneal carcinomatosis from gastric cancer. This treatment needs a critical evaluation for patients with a PCI ≥12. Furthermore, the accurate selection of patients suffering of PMGC by using the developed score can improve the OS of up to 24 months for a suitable group and it can avoid the extensive treatment for unsuitable patients.