Treatment Pathways and Outcomes in Unresectable Gastric Cancer: A Retrospective Cohort Analysis

The surgical management of advanced gastric cancer (AGC) ranges from diagnostic surgery (DS) to palliative procedures (PP) and cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). This study aimed to describe real-world surgical strategies and evaluate their impact on patient outcomes.

We retrospectively analyzed 158 patients with AGC treated between 2014 and 2024 at a tertiary center and categorized them into three groups: DS (n=94), PP (n=52), and CRS-HIPEC (n=12). Demographic data, perioperative outcomes, and survival metrics were compared using ANOVA, Chi-square tests, and Kaplan-Meier estimates. In the CRS-HIPEC pathway, all 12 (100%) patients underwent staging laparoscopy, multidisciplinary team review, neoadjuvant chemotherapy, and interval CRS-HIPEC.

Treatment selection was influenced by disease burden, symptom profile, and physiologic reserve. Patients undergoing CRS-HIPEC were younger (mean age 49.4 years, p=0.002) and had higher postoperative complication rates, nine of 12 (75.0%)-compared with PP, 21 of 52 (40.4%), and DS, seven of 94 (7.4%) (p<0.001). Median overall survival was longest after CRS-HIPEC (40.3 months), followed by PP (11.5 months) and DS (7.1 months). In the CRS-HIPEC cohort, median disease-free survival was 16.6 months.

Surgical strategies for unresectable AGC are heterogeneous and should be individualized. Palliative procedures can offer symptom relief and modest survival benefit in selected patients, though at the cost of morbidity and potential delays in systemic therapy. CRS-HIPEC, associated with prolonged survival in a small, highly selected cohort, should be regarded as hypothesis-generating. Multidisciplinary evaluation and careful patient selection remain central to optimizing outcomes.