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The peritoneal-plasma barrier is a pharmacologic entity of importance for treatment planning in patients with malignant tumours confined to the abdominal cavity. This physiologic barrier limits the resorption of drugs from the peritoneal cavity into the blood. The sequestration of chemotherapeutic agents improves their locoregional cytotoxicity and reduces their systemic toxicity. The physical nature of the peritoneal-plasma barrier has not been clearly defined. Further pharmacologic studies need to be performed in order to achieve a better understanding of this interesting metabolic phenomenom. At present, it is suspected that a diffusion barrier exists that consists of subserosal tissues or blood vessel walls. As postulated by Maher [29], the capillary wall appears to offer the dominant resistance to the transfer of larges solutes. The mesothelium and intersitium impede their movement to a lesser extent, and their removal during cytoreductive surgery does not affect the pharmacology of postoperative intraperitoneal chemotherapy.

A more modern treatment strategy for diffuse malignant peritoneal mesothelioma may be suggested (figure 3). Clinical suspicion of diffuse malignant mesothelioma (peritoneal carcinomatosis) calls for laparoscopy with evaluation of parietal and visceral peritoneum and multiple biopsies sufficient for definitive histologic diagnosis. Cytologic examination of ascitic fluid is not likely to be of benefit. CT of chest, abdomen, and pelvis is needed for evaluation of visceral involvement and the presence of distant metastases. Contrast enhancement of the gastrointestinal and urinary tract is necessary with the CT. Additional radiologic techniques for detection of distant metastases should be used if there are clinical or laboratory signs of extraperitoneal spread. After histologic diagnosis and extent of tumor spread have been documented, and if no symptoms of intestinal obstruction are present, the patient may be subjected to two to three courses of induction intraperitoneal chemotherapy. This will provide the clinician with important information on tumor response to chemotherapy, minimize tumor accumulation on bowel surfaces, and provide time for surgical conditioning. The time devoted to induction chemotherapy will allow occult distant metastases to be detected. In patients with a response or stable disease, cytoreductive surgery is attempted approximately 2 months after completion of induction chemotherapy. Surgery must be aimed at achieving complete or near-complete cytoreduction through the use of peritonectomy procedures [46,47]. Additional intraperitoneal chemotherapy should be administered intraoperatively and in the early postoperative period (figure 3). This treatment strategy may be the most feasible one according to existing knowledge of the natural history of diffuse malignant peritoneal mesothelioma. Only further phase II clinical trials can reveal the extent to which it is beneficial. Because of the rare occurrence of this disease, the quickest answer would come as a result of cooperative study by several groups experienced in these treatment modalities.

A prominent site for recurrence of retroperitoneal and visceral sarcoma is the abdominal cavity. In an attempt to understand the causation of local and regional recurrence, 21 sarcoma patients who had previously undergone "complete" surgical removal of the primary tumor were prospectively studied. Data were obtained retrospectively from the first operation and prospectively from the reoperative procedure at the Washington Cancer Institute. At the primary and reoperative surgeries, 9 abdominopelvic regions and 21 sites were scored and then cataloged in a standardized fashion. Tumor locations and surgical resections were statistically analyzed in an attempt to establish patterns of recurrence within the abdomen and pelvis. There was a significant difference in sites of recurrence when sarcomas that involved the parietal structures were compared with those that involved small bowel. Peritoneal implants (nodular recurrences) were uniformly present in both groups. In contrast, resection site recurrences were very common with primary sarcomas invested by parietal peritoneum, while they were absent in those covered by visceral peritoneum. When primary surgeries were compared with reoperations, there was an increasing intraabdominal dissemination; the mean number of regions increased from 1.81 to 5.13. The change in distribution of sarcoma deposits at reoperation was greatest in right upper (because of liver surface) central and pelvic abdominopelvic regions and lowest in the left upper and epigastrium. The four anatomic sites that revealed a significant increase in involvement at the time of recurrence were the greater omentum, liver surface, large bowel, and the cul-de-sac of Douglas (all p < 0.002). Regions with tumor involvement or regions subjected to surgical trauma at the time of primary sarcoma resection were significantly more likely to show sarcoma deposits than to be sarcoma free at reoperation. These data taken together may suggest that sarcoma tumor emboli are frequently present in the abdomen at the time of resection of the primary cancer and that these tumor emboli are entrapped in fibrinous material at or immediately adjacent to sites of surgical trauma and along narrow margins of resection. Tumor cell entrapment of sarcoma emboli released into the peritoneal cavity prior to or at the time of sarcoma resection may help explain the distribution of nodular and fusiform recurrence of abdominopelvic sarcoma.

Pseudomyxoma peritonei is a clinical entity that has lead to much confusion about its etiology, clinical manifestations, treatment, and prognosis. Pseudomyxoma peritonei is currently defined as a grade I mucinous adenocarcinoma that arises from a primary appendiceal adenoma. The clinical entity is defined by a redistribution phenomenon. This means that cancer cells from the appendix tumor are found localized at predetermined sites within the abdomen and pelvis but that the primary tumor may be small and inconspicuous. The small bowel is spared of mucinous tumor, while spaces beneath the hemidiaphragms and within the pelvis are filled by disease. The omentum is massively replaced by tumor in most patients. The disease, when treated by multiple surgical procedures, presents a median survival of approximately 2 years. Good results depend on early diagnosis and treatment before large volumes of disease and multiple surgical procedures lead to small bowel entrapment by tumor. In modern therapy using peritoneotomy procedures and intraperitoneal chemotherapy with mitomycin C and 5-fluorouracil, the long-term survival at 10 years approaches 80 percent.

A detailed analysis of the patterns of treatment failure of ovarian malignancy may lead to a more comprehensive understanding of the natural history of the disease. A hypothesis was generated that suggests treatment failure was caused by ovarian cancer persistence and by reimplantation of tumor emboli trapped within surgically traumatized tissues. Nine ovarian cancer patients who had previously undergone standard surgical removal of the primary cancer were prospectively studied at a reoperative procedure. The operative findings at the time of primary cancer surgery and reoperative surgery were scored for the presence of tumor in 9 abdominopelvic regions and 17 abdominopelvic sites. These data were then statistically analyzed. In 7 of the 9 patients ovarian cancer recurrence was associated with an increased intraperitoneal dissemination of tumor. A mean of 3.1 regions were involved at the time of the initial surgery and 5.3 were involved at reoperation. The regions most consistently involved were those in close proximity to the primary cancer. The anatomic sites that showed a preponderance of recurrence were the rectosigmoid colon, cul-de-sac of Douglas, left paracolic gutter, vagina, and abdominal incision. Traumatized sites always showed more cancer recurrence than nontraumatized sites. The vaginal cuff and abdominal incision, sites free of cancer after hysterectomy but at high risk for tumor cell entrapment, were disproportionately common sites for cancer found at reoperation. This study shows that in this reoperative setting ovarian cancer recurrence is most common in the pelvis and the left lower part of the abdomen. The cul-de-sac of Douglas and the rectosigmoid colon are anatomic sites at extreme risk for disease progression. These are sites in which ovarian cancer implants not removed by routine hysterectomy and bilateral salpingo-oophorectomy will persist. Also, sites traumatized by surgery were disproportionately involved by cancer at reoperation. These data may be interpreted to suggest that anatomic sites with cancer persistence and with cancer implantation induced by surgical trauma are the most common sites for ovarian cancer recurrence in this select group of patients.

In summary, confusion exists among clinicians regarding the possibilities of treatment for ovarian metastases in general, and of the Krukenberg tumors in particular. The ovaries themselves are easily removable irrespective of their sizes, but disappointing long-term results of oophorectomy alone leave most surgeons with only the choice of conservative therapy unless there is a debilitating tumor mass. In most patients nothing is done until surgical palliation becomes mandatory. There is a group of patients with isolated peritoneal dissemination of gastrointestinal cancers who are eligible for new treatment strategies. This group includes patients who have small-volume peritoneal spread or who can be completely cytoreduced, and those who have no evidence of liver or extraabdominal metastases. An aggressive approach with cytoreductive surgery and intraperitoneal chemotherapy with or without additional systemic chemotherapy should be considered for the treatment of selected patients.

The technical flaws that result in a leak from a low colorectal or a coloanal anastomosis are inadequate blood supply and tension on the suture line. An adequate blood supply is dependent on a patent and nontraumatized marginal artery. Lack of tension is achieved by gaining added length from the left colon through the release of its abdominal attachments. This chapter describes the maneuvers that allow progressive release of the left colon to provide a tension-free anastomosis to the low rectum, even with extensive resections of the sigmoid colon and portions of the descending colon. In most instances a well-vascularized and tension-free stapled anastomosis does not require a diverting ostomy. These maneuvers will result in a safer and less expensive colorectal resection.

Pseudomyxoma peritonei is a mucinous cancer of low biologic aggressiveness that disseminates widely throughout the abdominopelvic cavity prior to diagnosis. Complete control of the disease process on peritoneal surfaces should translate into long-term disease-free survival. In a series of 120 patients with pseudomyxoma peritonei, 46 were defined as treatment failures after cytoreductive surgery and regional chemotherapy. Clinical features that correlated significantly with treatment failure were tumor site (colon vs. appendix), histopathology grade (grade II vs. grade I), preoperative cancer volume, and completeness of cancer removal by cytoreductive surgery. For grade I histopathology, treatment failure was 10 times more common after incomplete versus complete cytoreduction. For grade II histopathology treatment failure was three times more common with incomplete cytoreduction. Death from other causes was more common over the age of 65, and stroke was the most common diagnosis. The major causes of morbidity and mortality were related to progressive disease in the abdomen causing intestinal obstruction and biliary obstruction. When treatment failures were categorized as surgical (failure to cytoreduce) versus medical (failure of chemotherapy to sustain a response), there were 27 surgical and 10 medical treatment failures. Improvements in the cytoreductive approach await the development of surgical technologies to increase the total clearance of cancer from the abdominal cavity and chemotherapy treatments that are complete enough to sustain control of small-volume residual disease on all peritoneal surfaces.

The relatively low incidence of abdominal adhesions following the use of postoperative intraperitoneal chemotherapy should not restrict the indications of these treatments. However, some drugs appear to have a documented sclerotic effect on the peritoneum causing intraabdominal adhesions. Studies should be conducted on drug dosage, drug scheduling, and the use of additional treatments such as nonsteroidal antiinflammatory or fibrinolytic drugs that could reduce adhesion formation after intraperitoneal infusion of vesicant drugs.

This chapter reported the pharmacokinetics and the toxicities of mitomycin-c (MMC) when administered as a hyperthermic intraperitoneal lavage after surgical resection of advanced primary or recurrent gastrointestinal cancer. Pharmacologic studies were performed in 10 patients and all adverse reactions were recorded in 20 patients. These 20 patients had advanced gastrointestinal malignancies with peritoneal carcinomatosis and underwent cytoreductive surgery prior to intraperitoneal lavage. Heated (42 degrees C) intraperitoneal mitomycin C was used in a lavage technique with 30 mg/3 1 of drug for 2 hours. The fluid was distributed throughout the abdominal cavity by vigorous external massage of the abdominal wall. This resulted in approximately 70 percent (21 mg) drug absorption from the perfusate. Urine output of MMC averaged 2.5 mg during the 2 hour procedure. Median peak blood levels of 0.25 micrograms/ml (range 0.11-0.41 micrograms/ml) were observed at 45-60 minutes into the procedure. Morbidity was low and was mainly related to the surgical procedures (prolonged ileus, postoperative fistulas) with mild to moderate drug-related myelosuppression. This new method of delivery of MMC and 5-FU should be explored in phase II clinical trials.

This chapter considered the observations that concern the spread of cancer emboli within the abdominal cavity. These collected observations begin to construct a pathophysiology that allows one to predict some important aspects of disease progression. The factors that should be considered are enumerated in Table 4. Taken together, these factors support an ordered phenomenon whose complete understanding will help design new and more effective treatment strategies.

In summary, the radologic appearance of peritoneal carcinomatosis and sarcomatosis is best understood with a thorough knowledge of the natural history of the disease. Computed tomography (CT) examinations of the abdomen and pelvis are insensitive to small volumes (< 5 cm) of diffuse peritoneal seeding. However, when larger volumes of peritoneal tumor are present, CT can be helpful defining the patients who are good candidates for complete cytoreduction (no small bowel disease) from those who are less likely to have a complete cytoreduction (extensive small bowel disease with clumping and obstruction). Thus CT examination plays a critical role in the identification of patients with mucinous tumors who are operative candidates. Further research is needed to improve sensitivity and in the monitoring of recurrence in patients with gastrointestinal cancer.

Peritoneal carcinomatosis is a major cause of surgical treatment failure in patients with colorectal cancer. Patients with this condition have in the past always had a lethal outcome. We reviewed the results of 56 consecutive patients treated by the cytoreductive approach. This involved surgery to maximally resect all cancer in the abdomen and pelvis in combination with early postoperative intraperitoneal chemotherapy with 5-fluorouracil (5-FU) and mitomycin C. All patients also had three cycles of adjuvant intraperitoneal 5-FU with systemic mitomycin C. An assessment of the clinical features that may affect prognosis was performed and critically analyzed statistically. A significant clinical feature was defined as one with a p value > or = 0.05. Small lesion size of implants present in the abdomen and pelvis at the time of exploration correlated with a good prognosis (p = 0.0025). A complete cytoreduction with tumor removed to < 0.25 cm correlated with a good prognosis (p = 0.0001). A limited involvement of the five abdominal regions was an important determinant of prognosis, with a p value of 0.0739. Finally, a mucinous histologic type correlated adversely with prognosis when compared with adenocarcinomas (p = 0.0434). These data taken together may suggest that patients with small-volume peritoneal seeding should routinely be treated with cytoreductive surgery and aggressive regional and systemic chemotherapy in an attempt to achieve long-term disease-free survival in this group of poor prognosis patients.

Peritoneal carcinomatosis from appendical or colorectal cancer has been regarded as a fatal clinical entity. We used cytoreductive surgery and intraperitoneal chemotherapy to treat consecutive patients with peritoneal carcinomatosis. There were 43 colorectal and 104 appendiceal cancer patients. The mean follow-up was 32 months, with a range of 0-140 months. Clinical features that showed prognostic significance included appendiceal versus colorectal primary (p < 0.0001), grade I versus grades II and III histopathology (p < 0.0001), complete versus incomplete cytoreduction (p < 0.0001), lymph node-negative versus lymph node-positive primary tumor (p < 0.0001), volume of peritoneal carcinomatosis present preoperatively for colon cancer (p < 0.0002), and nonmoderate versus heavy prior surgery (p < 0.0043). Features with no statistical prognostic significance include tumor volume for appendiceal cancer, age, sex, number of cycles of chemotherapy, operative time, complications, blood loss, and institution providing treatment. From these prognostic features, four staging groups were identified and 5 year survival was estimated by the product-limit survival method. Group I patients (n = 61) were those with grade I histology, no lymph node metastases, and a complete cytoreduction (survival at 5 years = 90%). Group II (n = 20) patients are those with grade II or III histology, no lymph node metastases, and a complete cytoreduction (62%). Group III patients (n = 22) had any histology, lymph node metastases, and a complete cytoreduction (45%). Group IV patients (n = 44) had an incomplete cytoreduction (12%). Peritoneal carcinomatosis is a treatable condition in selected patients with a possibility for long-term disease-free survival.

Decisions regarding the treatment of cancer depend on the anatomic location of the malignancy and the biologic aggressiveness of the disease. Some patients may have isolated intraabdominal seeding of malignancy of limited extent or of low biologic grade. In the past these clinical situations have been regarded as lethal. We have used the cytoreductive approach to achieve long-term disease-free survival in some patients with peritoneal carcinomatosis, peritoneal sarcomatosis, or mesothelioma. The cytoreductive approach may require six peritonectomy procedures to resect or strip cancer from all intraabdominal surfaces. These are (1) greater omentectomy-splenectomy, (2) left upper quadrant peritonectomy, (3) right upper quadrant peritonectomy, (4) lesser omentectomy-cholecystectomy with stripping of the omental bursa, (5) pelvic peritonectomy with sleeve resection of the sigmoid colon, and (6) antrectomy. These peritonectomy procedures and preparation of the abdomen for early postoperative intraperitoneal chemotherapy are described.

Reoperative surgery was used as a treatment for patients with recurrent obstructing cancer. In this group of patients intraperitoneal chemotherapy was used in an attempt to prolong the beneficial effects of treatment. This aggressive approach may be recommended irrespective of patient performance status if the patient is not terminally ill. This treatment was associated with a high rate of postoperative complications (55%) but low mortality (7%). To avoid or reduce the incidence of postoperative complications, this treatment should be performed only by an experienced surgical oncologist. Long-term benefits of this treatment were related to biologic factors reflected by cancer origin in the appendix, low-grade tumor histopathology, and a free interval of > 2 years. Treatment-related factors were completeness of cytoreduction and administration of intraperitoneal chemotherapy. The best outcome was achieved with pseudomyxoma peritonei of appendiceal origin with a time interval between surgeries of 2 or more years, a complete cytoreduction, and treatment with intraperitoneal chemotherapy. This treatment modality can be recommended for palliation of patients with recurrent obstruction due to other gastrointestinal and ovarian malignancies, although, long-term results may not be so encouraging as with appendix tumors. In the group of colorectal cancer patients treated by aggressive reoperative surgery and intraperitoneal chemotherapy, 35.3 percent survived 1 year, which differs significantly from the 4-5 month survival after treatment by the standard approach.

The following methodologies may be strictly applied to quantitatively evaluate patients with peritoneal carcinomatosis or sarcomatosis in regard to disease progression or regression: (1) Preoperative CT scan and the intraoperative assessment of cancer extent is analyzed region by region (AR-0-12) and an estimation of tumor volume (V0-V3) is evaluated according to the standardized scoring system previously described. At laparotomy, the volume of tumor nodules to adjacent organs, the viscosity (mucinous vs. solid) of tumor mass, and the pattern of distribution is assessed. (2) Radiologic abdominopelvic CT parameters that predict an incomplete cytoreduction are focal obstructions of bowel by CT assessment and tumor involvement of proximal ileum (AR-11). (3) The extent of prior surgical interventions (PS-1 through PS-3) must be recorded because aggressive deep dissections without perioperative chemotherapy severely jeopardize the possibility for complete cytoreduction. (4) Many tumor samples should be sent for histopathologic analysis. A proportion of mucin > 80% confirms a mucinous cancer. The malignant differentiation of cells, stroma morphology, the presence of signet ring cells, and evidence of invasion are used to grade cancers as mucinous tumor grade 0-3 (MTG-0 through MTG-3). (5) Once the cytoreductive procedure is accomplished, the surgeon estimates the residual volume of disease. (6) Objective response criteria from CT scan, tumor marker, and radiolabeled monoclonal antibody studies are necessary in a regular follow-up schedule.

Advanced primary and recurrent ovarian cancer within the pelvis presents a difficult oncologic problem in management. Based on a failure analysis of ovarian cancer, a new procedure was devised for the complete surgical removal of all visceral and parietal pelvic surfaces. Resections included the uterus, ovaries, rectosigmoid colon, and the complete pelvic peritoneum, including the cul-de-sac of Douglas. An immediate low rectal anastomosis with a circular stapler was utilized in all patients. Intraperitoneal chemotherapy was employed on postoperative days 1-5 to prevent further implantation of cancer cells. The technical experience with 12 women is reported. The circular stapler resulted in no anastomotic leakage and no anastomotic bleeding. There were no postoperative deaths. These results suggest that complete pelvic peritonectomy combined with early postoperative intraperitoneal chemotherapy carries an acceptable morbidity and mortality, and is a new treatment strategy that may be considered for advanced malignancy in the pelvic cavity. This surgical technique may be pursued in an attempt to optimize the management of ovarian cancer with peritoneal seeding.

Intraoperative hyperthermic lavage with cisplatin was studied in 8 patients with peritoneal carcinomatosis and sarcomatosis. A dose of 50 mg/m2 of cisplatin used for 2 hours with an intraperitoneal temperature of 41 degrees to 43 degrees C was used. Pharmacokinetic studies showed that cisplatin left the abdomen and pelvis by simple diffusion with a half life of 48 minutes in the peritoneal fluid. Eighty-six percent of the drug was absorbed into the plasma within 2 hours but only 6.9% was excreted into the urine. The area under the curve ratio for peritoneal fluid to plasma was 6.9. The quantity of cisplatin in tissue from the abdomen or pelvis was extremely variable. It was 1.85-10.28 micrograms cisplatin/g tumor and < 0.57-7.90 micrograms/g normal tissue. Comparison of pharmacologic parameters of hyperthermic to normothermic cisplatin administration showed no significant differences.

The clinical significance of occupational exposure to antineoplastic agents is controversial. Accrued evidence does not seem to indicate mutagenicity, carcinogenicity, and tertogenicity when exposure is limited by proper precautions. However, medical surveillance of personnel continually exposed to these cytotoxic agents will aid in early detection of any problems should they occur. Because the current fiscal milieu constantly emphasizes cost containment, true prevention means an intense worker education program. Personnel continually exposed to these cytotoxic agents should have scheduled health checkups twice a year, and exposure frequency should be reported to the employee's personal physician.

Early postoperative intraperitoneal Adriamycin (doxorubicin) may be an excellent adjuvant treatment that, when combined with complete surgical removal, may markedly improve the survival of patients with visceral and retroperitoneal sarcoma. Even if its only effect were to decrease the incidence of sarcomatosis, a markedly improved quality of life for these patients would be achieved. We suggest that these improved local treatments should be combined with aggressive systemic therapy in order to develop an optimal adjuvant approach to the treatment of sarcoma. Prospective studies to test the efficacy of these treatment strategies are needed.

When performing reoperative surgery or in primary cancer resections, where margins of excision are narrow and tumor spillage is a risk, dissection by electrosurgery with a ball-tip should be considered. This technique preserves the surgeon's view of the operative field by electroevaporation of irrelevant normal or tumor tissues, provides complete small vessel hemostasis, and prevents charring. Tumor spillage is minimized and margins of resection are maximized by the ball-tip dissection technique.

Colorectal cancer patients may present with peritoneal seeding of the abdominal cavity or develop it as recurrent disease. Peritoneal carcinomatosis has been regarded as a uniformly lethal clinical entity with no specific plan for management. Twenty-six patients with an established diagnosis of isolated spread of adenocarcinoma or cystadenocarcinoma of colorectal or appendiceal origin to peritoneal surfaces were treated with a combination of intraperitoneal 5-fluorouracil and intravenous mitomycin C. Three cycles of chemotherapy of 5 days each in duration were given once a month for 3 months. Two to 4 months after completion of chemotherapy, exploratory surgery and a cytoreductive procedure occurred. Responses to intraperitoneal chemotherapy were recorded at the time of cytoreductive surgery. Four of five patients with low-volume intraperitoneal adenocarcinoma had complete responses to induction chemotherapy. None of 18 patients with moderate- or large-volume cystadenocarcinoma had complete responses. The surgical procedure was facilitated by chemotherapy responses in patients with moderate-volume peritoneal carcinomatosis but not if large-volume disease was recorded. Surgical complications in patients treated by the induction approach were more frequent (p = 0.01) when compared with matched patients without intraperitoneal chemotherapy prior to cytoreductive surgery. This data may suggest that patients with low- or moderatevolume peritoneal carcinomatosis should be treated with induction chemotherapy because of a high rate of responsiveness. Large-volume peritoneal carcinomatosis from grade I cancer should have cytoreductive surgery prior to chemotherapy because of less responsiveness and the frequent surgical morbidity observed with the induction approach.

The peritoneal plasma barrier (PPB) is a pharmacologic entity of importance for treatment planning in patients with malignant tumors confined to the abdominal cavity. We have examined the pharmacokinetics of the PPB by sampling abdominal fluid following intravenous mitomycin C (MMC) administration. The study included 15 cycles of treatment in seven patients with peritoneal carcinomatosis from colorectal cancer. Five patients were studied twice and one patient was studied three times for a total of 15 cycles. Patients were treated with intraperitoneal 5-fluorouracil (5-FU) at 20 mg/m2 in 11 of fluid. Between 250 and 500 ml of ascites remained after the 23 hour intraperitoneal dwell. On day 3, MMC (12 mg/m2) was administered intravenously as a 2-hour continuous infusion in 200 ml of dextrose solution. The concentration of MMC was determined in plasma, peritoneal fluid, and urine by high performance liquid chromatolography (HPLC) at frequent intervals for 8 hours. The area under the curve (AUC) for plasma as related to peritoneal fluid was three times greater for plasma in one cycle, two times greater for plasma in three cycles, 1.5 times greater for plasma in five cycles, and the same in six cycles. AUC ratios showed a correlation with the extent of peritoneal stripping at the prior surgical procedure 6 weeks to 14 weeks previously. We conclude that malignant ascites may be less exposed to chemotherapy than systemic tumor nodules when the intravenous route of drug administration is used. This inadequacy is even more pronounced in patients who have had extensive abdominal surgery.

The rationale and the treatment strategies for peritoneal carcinomatosis have gained prominence over the last decade. Their definite contribution to the management of gastrointestinal cancer has been established. The significant contributions are summarized in Table 7.

Early postop intraperitoneal adriamycin may be a excellent adjuvant treatment, which, when combined with the R2 gastric resection, may markedly improve the survival of patients with gastric cancer. Even if its only effect were to decrease the local recurrence rates, a markedly improved quality of life for gastric cancer patients would be achieved. We suggest that these improved local treatments should be combined with aggressive systemic therapy in order to develop an optimal adjuvant approach to the treatment of gastric cancer.