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A new treatment strategy involving cytoreductive surgery (CRS) combined with perioperative intraperitoneal (IP) chemotherapy was proposed in 1999 by the Peritoneal Surface Oncology Group International, and the strategy is now justified as a state-of-the-art treatment to improve the long-term survival of patients with peritoneal metastasis (PM). To achieve cure in the patients with PM, complete removal of macroscopic tumors and eradication of micrometastasis on the peritoneum, left after CRS are essential. Systemic chemotherapy is not indicated for the treatment of PM. In contrast, intraperitoneal (IP) chemotherapy brings about significantly higher locoregional dose intensity in the peritoneal cavity and subperitoneal tissues. In combination with anticancer drugs, hyperthermia enhances cytotoxicity against cancer cells.This article provides a systematic overview of PM from various cancers including gastric, colorectal, small bowel, appendiceal cancer, and mesothelioma. It also includes all the essential aspects of therapy.CRS plus perioperative intraperitoneal chemotherapy is safe with acceptable morbidity and mortality. It is justified as a standard treatment to improve the long-term survival of patients with PM and is now performed with curative intent for PM from various malignancies.

BackgroundCytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) improves survival in selected patients with peritoneal metastasis (PM) from colorectal cancer (CRC). However, little has been reported on characteristics and clinical course of long-term survivors with CRC-PM beyond 5 years. The objective of this study was to identify the clinical and oncological features affecting long-term survival of CRC-PM after comprehensive treatment.MethodsBetween January 1990 and April 2015, CRC-PM patients who underwent CRS with or without HIPEC in two Japanese tertiary hospitals were analyzed. Clinicopathological parameters and therapeutic details for long-term survivors (patients surviving ≥ 5 years after CRS) were described and compared with those for non-survivors (patients surviving ResultsThe study identified 236 patients with CRC-PM who underwent CRS, with a median follow-up period of 2.5 years. Thirty-three patients (14.0%) were considered as long-term survivors. Compared with non-survivors, long-term survivors had a lower median peritoneal cancer index (PCI) [4 (1–27) vs 9 (0–39),ppp= 0.018]. Regarding histopathology, long-term survivors more frequently had mucinous adenocarcinoma than non-survivors [8/33 (24.2%) vs 27/203 (13.3%)] and less likely exhibited poorly differentiated or signet ring cell carcinoma [2/33 (6.1%) vs 48/203 (23.7%)] (pConclusionsOne in seven patients with CRC-PM achieved the long-term milestone after CRS. A long-term survival was associated with the presence of low PCI, CCR-0, metachronous onset, and mucinous histology.

Simple Summary Approximately 1% of all patients with colorectal cancer, and 15% of patients with peritoneal metastasized colorectal cancer present with the subtype of signet ring cell, which is associated with inferior oncological outcome and reduced overall survival. The evidence whether patients with signet ring cell subtype are benefiting from cytoreductive surgery and hyperthermic intraperitoneal chemotherapy is limited. The aim of this large bicentric retrospective study including 60 patients with this subtype was to explore the survival and define predictive factors of these patients. Median overall survival was 14.4 months, while small bowel PCI > 2 (HR: 6.5; p = 0.008) was the strongest predictive factor for inferior patient survival. The study concludes, that after thoroughly selection patients for CRS and HIPEC, even patients with signet ring cell subtype of colorectal cancer may benefit from this concept. Abstract Signet ring cell subtype (SRC) of colorectal cancer (CRC) is a rare subtype and occurs in approximately 1% of all patients with CRC. Patients with peritoneal metastasis (PM) of SRC have a poor prognosis, and this subtype is frequently considered as a contra-indication for extensive surgical treatment. This retrospective study from two dedicated peritoneal surface malignancy centers in Japan included all patients treated with CRS ± hyperthermic intraperitoneal chemotherapy (HIPEC) between July 1994 and December 2017 from a prospectively maintained database. Preoperative, operative, and postoperative parameters were recorded, including complication rates and follow-up. Sixty of the 320 patients treated with CRS due to CRC were diagnosed with SRC subtype. The mean age of the patients was 51.4 years, and the mean peritoneal carcinomatosis index (PCI) was 13.1. Complete cytoreduction was achieved in 61.7% of cases. The postoperative morbidity rate was 25% and the mortality rate was 1.7%. The median overall survival (OS) was 14.4 months. Cox regression analysis revealed small bowel PCI > 2 (hazard ratio (HR) 6.5; p = 0.008) as the most important factor for OS. With accurate patient selection (e.g., PCI ≤ 12 or small bowel PCI ≤ 2), even patients with PM of CRC with SRC subtype may benefit from CRS and HIPEC, with median OS from 17.8 to 20.8 months and 5-year OS of 11.6%.

Neoadjuvant intravenous chemotherapy in patients with pseudomyxoma peritonei (PMP) has not shown convincing results. The effectiveness of neoadjuvant intraperitoneal (IP) chemotherapy has never been reported. This prospective, non-randomized phase II study included patients with PMP treated between May 2017 and December 2018, who were not considered suitable for primary cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). The majority of patients were treated with laparoscopic HIPEC (oxaliplatin 200 mg/m2, 60 min, 43 &deg, C). IP chemotherapy was started 2 weeks after docetaxel 40 mg/m2 + cisplatin 40 mg/m2, accompanied by oral S1 (tegafur, gimeracil, and oteracil) (50 mg/m2) for 14 days, followed by one week rest. Clinical parameters and complications were recorded. In total, 22/27 patients qualified for CRS and HIPEC after neoadjuvant treatment. A complete cytoreduction (Completeness of cytoreduction Score 0/1) could be achieved in 54.5%. The postoperative morbidity rate was 13.6% and mortality was rate 4.5%. In total, 20/22 patients had major pathological tumor responses. The mean drop in CEA was 28.2% and in the peritoneal carcinomatosis index (PCI) was 2.6. Positive or suspicious cytology turned negative in 69.2% of patients. Thus, for PMP patients who were not amenable for primary surgery, the majority received complete cytoreduction after treatment with neoadjuvant IP chemotherapy, with satisfying tumor regression and with low complication rates. The oncological benefit in terms of survival with this new treatment regimen needs to be proven.

Peritoneal Surface Oncology Group International(PSOGI)proposed a novel treatment, named comprehensive treatment for peritoneal metastasis(PM)from colorectal cancer(CRC). The present study demonstrated the efficacies of the treatment regarding the peritoneal sectors and organs involved with PM from CRC.Among 365 patients received laparotomy, 278 CRC patients with PM underwent complete cytoreductive surgery(CC-0).After CC-0 resection Grade 3, Grade 4, and Grade 5 postoperative complication were found in 20(7.2%), 26(9.3%), and 6(2.2%). Five- and 10-year survival rate(YSR)of CC-0 resection were 24.5%, and 11.6% with median survival time(MST)of 42.0 months. Regarding the peritoneal cancer index(PCI)of small bowel(SB-PCI), all patients of PCI B3 died of the disease. In contrast, 10-YSR of patients with SB-PCI of 0, 1, and 2 were 26.1%, 19.5%, and 6.2%, respectively. Ten-YSR of patients with the number of involved peritoneal sectors C9 ranged from 6.9% to 29.8%. MST of patients with PM in each peritoneal sector(sector 0 to sector 8)ranged from 26.4 months to 49.2 months, and 10-YSR ranged from 4.2%to 17.2%. Ten-YSR of patients with involvement of rectum, stomach, liver capsule, seminal vesicle, ureter, uterus, or ovary ranged from 0% to 16.9%.From the present data, PM should be removed aggressively to achieve complete cytoreduction, when the patients with PCIC26, involved peritoneal sectorsC9 and SB-PCIC2 are supposed to receive complete cytoreduction of PM.

Mechanisms of peritoneal metastasis (PM) formation remain unclear. It has long been considered that the establishment of PM is a multi-step process. Here are the recent new concepts of the formation of PM, in terms of three patterns of PM: trans-mesothelial, trans-lymphatic, and superficial growing metastasis. Trans-mesothelial metastasis is established through detachment of cancer cells, adhesion on distant peritoneal surface, invasion into submesothelial tissue, and proliferation. Trans-lymphatic metastasis develops by the migration of peritoneal free cancer cells (PFCCs) into omental milky spots and/or initial lymphatic vessels. Superficial growing metastasis is established by growing of PFCCs on the peritoneal surface after trapping or adhesion to pocket-like structure or pouch in pelvic cavity or in peritoneum absorbed by negative pressure generated omental milky spots or initial lymphatic vessels.

This study was conducted to verify the effects of cytoreductive surgery (CRS) combined with perioperative chemotherapy (POC), using neoadjuvant intraperitoneal/systemic chemotherapy (NIPS), extensive intraperitoneal lavage (EIPL), and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal metastasis from gastric cancer (GC-PM). Combination of these treatments is called “comprehensive treatment.” The survival rate after comprehensive treatment was significantly superior to that after systemic chemotherapy. Complete cytoreduction and peritoneal cancer index (PCI) less than cutoff level after NIPS are independent prognostic factors. NIPS could bring stage reduction of PM and eradicate micrometastasis in the peritoneal cavity, resulting in an increase in complete cytoreduction rate of PM. At present, 10% of GC-PM can be cured by the comprehensive treatment because micrometastasis left behind after complete cytoreduction of macroscopic PM might be completely eradicated by HIPEC and postoperative chemotherapy.

Summary Background: Neoadjuvant Intraperitoneal/ Systemic Chemotherapy (NIPS) is considered effective method to treat Peritoneal Metastasis (PM) from Gastric Cancer (GC). The objective of the present study is to verify the effect of NIPS on Lymph Node Metastasis (LNM). Methods: During the last 18 years, we enrolled 107 and 136 patients who underwent D2-gastrectomy after NIPS and D2-gastrectomy alone (non-NIPS group), respectively. Results: The total number of LNMs in the non-NIPS group and NIPS group was 14.8 ± 13.9 and 4.6 ± 5.9, respectively (P NIPS is a very effective method to control LNM from GC. After intraperitoneal administration of chemotherapeutic drug, extremely higher concentrations of chemotherapeutic drug are absorbed through omental milky spots, and the efferent lymphatic fluid drain into the regional lymph nodes of stomach. As a result, regional LNM of stomach are exposed with extremely higher concentrations of chemotherapeutic drugs than systemic chemotherapy. This feature of the lymphatic circulation accounts for the much greater effects of NIPS on LNM. Synopsis: Neoadjuvant intraperitoneal/systemic chemotherapy is effective not only peritoneal metastasis but also lymph node metastasis from gastric cancer. Keywords: Gastric cancer; Lymph node metastasis; Neoadjuvant intraperitoneal/systemic chemotherapy

Treatment failure after complete cytoreduction for appendiceal mucinous carcinoma peritonei (AMCP)has not been fully investigated. The present study was performed to clarify the risk factor for recurrence after complete cytoreduction for AMCP.A total of 400 patients with AMCP who underwent complete cytoreductive surgery combined with perioperative chemotherapy were investigated.Documented recurrence was developed in 135 (33.8%)patients. The 5- and 10-year progression-free survival was 51% and 49%, respectively. By multivariate analysis, histological subtype of peritoneal disease(high-grade AMCP[AMCP-H]and AMCP-H with signet ring cells), serum CA19- 9 level, and PCIB20 were significantly associated with reduced progression-free survival. In contrast, histologic subtype of mucin without epithelial cells(MWEC)showed the lowest risk for recurrence. Eighty-six patients had localized intra-abdominal recurrence, and 42 patients had diffuse peritoneal recurrence. Recurrence was found in the various peritoneal sectors. Eighty-one patients underwent complete cytoreduction for the recurrence, and the overall survival 5-year survival rate after secondary cytoreduction was 49%.Risk factors for recurrence were histologic subtype, PCI cutoff level, and serum CA19-9 levels. Aggressive second attempt of cytoreduction in patients with localized recurrence improved the survival.

The current standard of treatment for malignant peritoneal mesothelioma(MPM)is cytoreductive surgery(CRS)plus perioperative intraperitoneal or systemic chemotherapy(comprehensive treatment), The present study was performed to clarify the prognostic factors of PMP after comprehensive treatment.Among 63 patients with MPM, male and female patients were 34 and 29. CRSwas performed in 47 patients and complete cytoreduction(CC-0) was performed in 14(22%)patients. Mean numbers of resected peritoneal sectors and organs were 5.2(1-13), and 2.9(0- 9), respectively. Hyperthermic intraperitoneal chemoperfusion(HIPEC)was performed in 27 patients. Grade 1/2, Grade 3, and Grade 4 complications were experienced in 5, 6, and 3 patients, respectively. One patient died of sepsis, and the mortality rate was 2.3%. Independent prognostic factors for favorable prognosis were performance of HIPEC, peritoneal cancer index (PCI)score C12, no distant metastasis and histologic epithelial type. Relative risk of no HIPEC, PCI score B13, presence of distant metastasis and non epithelial type were 7.69, 22.1, 3.6 and 3.9, respectively.Risk factors for death after comprehensive treatment were no HIPEC, PCI score B13, and non epithelial type. However, only 11(17%)patients showed PCI score C12. Accordingly, PCI score should be reducedC12 before CRSby neoadjuvant chemotherapy.

In this review, Japanese experience of cytoreductive surgery and perioperative chemotherapy is described. The new concept of peritoneal metastasis (PM) type, i.e., trans-mesothelial, trans-lymphatic, and superficial growing metastasis type was proposed in 2012. Surgeons should perform peritonectomy according to the type of PM. Since 1980, Japanese surgical oncologists have been spearheading the use of cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemoperfusion (HIPEC) as treatment for PM from gastric cancer. Two RCTs were conducted to verify the effect of HIPEC for the prophylaxis of peritoneal recurrence after curative resection of advanced gastric cancer. These two studies indicated that HIPEC is effective in preventing peritoneal recurrence of gastric cancer with serosal invasion. In 2002, intraperitoneal chemotherapy using taxans was developed for the treatment of PM from gastric cancer and led to the development of neoadjuvant intraperitoneal/systemic chemotherapy (NIPS), which was reported in 2006. In 2009, extensive intra-operative peritoneal lavage (EIPL) was developed, and contributed to the remarkable improvement in survival of patients with positive lavage cytology as demonstrated by prospective randomized clinical trials. In 2017, the Peritoneal Surface Oncology Group International proposed the value of complete cytoreduction and peritoneal cancer index cut-off as independent prognostic factors after CRS for gastric cancer with PM. Founded in 2016, the Japanese/Asian School of Peritoneal Surface Oncology (JASPSO) trains beginners to perform CRS and HIPEC safely. Sixteen students have already graduated from JASPSO and started to perform the treatment in their home countries.

To analyze the role of cytoreductive surgery(CRS)plus perioperative chemotherapy on the survival of colorectal cancer(CRC)patients with metachronous peritoneal metastasis(PM). A comprehensive treatment consisting of neoadjuvant chemotherapy plus CRS was performed in 291 CRC patients. Among the 291, 142 and 149 patients had synchronous and metachronous PM, respectively. The results showed no survival difference between the 2 groups. Median survival time(MST)of patients with metachronous PM with complete cytoreduction(CCR-0), small bowel(SB)-PCIC2, PCIC14 and differentiated histologic type ranged from 3.1 to 4.1 years. Five-year survival rates of metachronous group of the CCR-0, SB-PCIC2, PCI C14 and differentiated histologic type ranged from 25.8 to 38.9%. However, the 5-year survival rates of the incomplete cytoreduction(CCR-1), SB-PCIB3, PCIB15 and poorly differentiated type were significantly lower than those of the CCR-0, SB-PCIC2, PCIC14 and differentiated histologic type. Postoperative Grade 3, and Grade 4 morbidity were experienced in 11(5.8%)and 16(10.7%)in metachronous group. Mortalities of metachronous group were 1.3%(2/149). The comprehensive treatment can be performed safely and improves the survival of CRC patients with metachronous PM. After NAC, patients with SB-PCIC2, PCIC14 and differentiated type of histology are candidates for CRS, and CCR-0 resection combined with HIPEC is recommended.

Ovarian growing teratoma syndrome (GTS) is a rare disease characterized by growth of a benign tumor during or after chemotherapy, following the removal of germ cell gonadal cancers. Although benign, GTS tumors grow gradually and may compress surrounding organs. In addition, up to 3% of GTS cases can undergo malignant transformation. It is, therefore, needed to treat GTS. No standardized management protocol has been established to treat GTS; however, surgical resection is likely the only effective treatment because tumors in GTS are resistant to chemotherapy and radiation therapy. However, complete resection with conventional procedures is sometimes difficult when peritoneal metastasis is widespread. We report a rare case of ovarian GTS with widespread peritoneal metastases, which was totally resected by peritonectomy procedures. A 45-year-old Japanese woman was initially diagnosed with an immature teratoma grade 3, which was treated by hysterectomy and bilateral salpingo-oophorectomy. Adjuvant chemotherapy was performed after surgery with bleomycin, etoposide, cisplatin, and other chemotherapies. Due to recurrence of a chemoresistant tumor and normalization of tumor markers, GTS was suspected. She was referred to our institute, and complete cytoreductive surgery was performed using peritonectomy procedures, including parietal peritoneal resection, greater omentectomy, lesser omentectomy, rectosigmoid colectomy, diaphragm dissection, and cholecystectomy. A complete cytoreduction with no visible residual tumor tissue was achieved.

Our aim was to clarify the effects of neoadjuvant hyperthermic intraperitoneal chemoperfusion (NLHIPEC) followed by intraperitoneal/systemic chemotherapy (NIPS) on peritoneal metastasis from gastric cancer. After carrying out exploratory laparoscopy to determine the peritoneal cancer index (pretreatment PCI: Pre-PCI) in 150 patients, we performed NLHIPEC for 60 min. with peritoneal port placement: a series of 3-week cycles of NIPS using S1, docetaxel, and cisplatin two weeks after NLHIPEC: performed cytoreductive surgery in 86 patients four weeks after NIPS, and subsequently measured PCI (Post-PCI). Positive cytology in 38 patients changed to negative in 26 (68.4%) patients at laparotomy. The post-PCI (6.7±7.8) was significantly lower than the pre-PCI (10.6±10.2) (P=0.0001). The PCI was ≥14 in 30 patients at pretreatment and ≤13 in 19 (63.3􀀁) of these patients at posttreatmjent. Post-PCI cut-off level (≤13 vs ≥14) and cytology after NIPS (negative vs positive) emerged as independent indicators of prognosis. Postoperative mortality was 1.2% (1/86). NLHIPEC and NIPS are safe and effective modalities for reducing Post-PCI below the cut-off level and eradicating peritoneal free cancer cells.

From 2009 to 2016, 9 female patients with multicystic peritoneal mesothelioma (MCPM) underwent 11 cytoreductive surgeries (CRS). Mean age at diagnosis was 50.6 (range, 43-71). Mean peritoneal cancer index was 8.9 (range, 2~33). Most frequent peritoneal sector involved was pelvic peritoneum in 7 patients, and greater omentum was involved in 6 patients. Eight and 1 patients had complete CRS and incomplete CRS, respectively. Except 1 patient, 8 patients had multiple cysts on different peritoneal sectors, and diffuse involvement on peritoneal surface was found in 2 patients No patients had lymph node metastasis or extraperitoneal spread. However, 3 patients showed pushing invasion to small bowel mesentery, colon, umbilicus and stomach. Median- follow-up was 46 months (range 4-120). At the time of the present analysis, all patients were alive. One patient recurred in peritoneal cavity 47 month after complete cytoreduction. Peritoneal free-floating cysts (PFFC) were found in 8 of 9 (88.9%) patients. Sizes of PFFC ranged from 1 mm to 2 cm in diameter and the inner surfaces were covered with mesotheliallike cells. MIB-1 labeling rates of PFFC ranged from 0.1% to 2.0%. These results indicate that PFCC may attach on the orifice of subperitoneal lymphatic vessels, and may become metastatic. The present study strongly suggests that MCPM has a potentially malignant behavior. This category of disease is composed of 2 types: diffuse type and localized type with borderline malignant potential. PFFC have an important role in the formation of peritoneal metastasis.

In the past, peritoneal metastasis (PM) was considered as a terminal stage of cancer. From the early 1990s, however, a new comprehensive treatment consisting of cytoreductive surgery and perioperative chemotherapy has been established to improve long-term survival for selected patients with PM. Among prognostic indicators after the treatment, completeness of cytoreduction is the most independent predictors of survival. However, peritoneal recurrence is a main cause of recurrence, even after complete cytoreduction. As a cause of peritoneal recurrence, small PM may be overlooked at the time of cytoreductive surgery (CRS), therefore, development of a new method to detect small PM is desired. Recently, photodynamic diagnosis (PDD) was developed for detection of PM. The objectives of this review were to evaluate whether PDD using 5-aminolevulinic acid (ALA) could improve detection of small PM.

Treatment failure after complete cytoreduction for peritoneal metastasis(PM)from colorectal cancer(CRC)has not been fully investigated. The present study was performed to clarify the risk factors for recurrence after complete cytoreduction for CRC with PM and the role of repeat surgery for recurrence.A total of 205 patients with CRC who underwent complete cytoreductive surgery combined with perioperative chemotherapy were investigated.Recurrence occurred in 149(73%)patients. The 5-year overall and progression-free survival rates were 26%and 7%, respectively. By multivariate analysis, positive cytology, serum CEA level higher than normal range, and small bowel peritoneal cancer index B3 were significantly associated with reduced progression-free survival. Blood-borne recurrence was found in 62 (44%)of 149 patients. Repeat surgery was performed in 44(30%), and complete removal was performed in 28(64%) patients. Long-term survival after repeat surgery was experienced in patients with localized peritoneal recurrence and/or liver recurrence.This study showed that a second attempt at cytoreduction in patients with localized intra-abdominal and liver recurrence is of benefit. Blood-borne recurrence was found in 44% of recurrent patients. The prophylaxis of recurrence should therefore be performed using systemic chemotherapy after CRS plus HIPEC.

Patients with curatively resected gastric cancer patients with positive peritoneal wash cytology are called P0/Cy1 status. The aim of the present study is to verify the survival benefit of the comprehensive treatment for patients with P0/Cy1 status. Twenty gastric cancer patients were diagnosed as P0/Cy1 by laparoscopy or laparotomy, and were treated with a comprehensive treatment consisting of neoadjuvant intraperitoneal/systemic chemotherapy (NIPS), cytoreductive surgery (CRS) consisting of gastrectomy with lymph node dissection and peritonectomy, intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) and postoperative systemic chemotherapy. At the second look laparotomy, the peritoneal wash cytology became negative in 15 patients. No grade 3, 4, 5 complications were experienced after second look operations for CRS. Median follow-up time is 3.7 years. Eight patients died of recurrence, but the other 21 patients are alive without recurrence. Five-year survival rate was 42%. The present study demonstrated the efficacy and safety of the comprehensive treatment on the gastric cancer patients in P0/Cy1 status.

In the past, peritoneal surface malignancy (PSM) was considered as a final stage of cancer, and patients were offered the best supportive care. Recently, a new therapeutic alternative approach based on the combination of surgery with chemotherapy was developed. In this curative intent, the macroscopic disease was treated with cytoreductive surgery (CRS) combined with perioperative chemotherapy, including neoadjuvant chemotherapy, hyperthermic intraoperative intraperitoneal chemotherapy, extensive intraoperative peritoneal lavage and early postoperative intraperitoneal chemotherapyThis article reviews the mechanisms of the formation of PSM, quantitative estimation of PSM and residual disease, multimodal treatment, value of laparoscopy, prognostic factors and patients' selection for the multimodal therapy.Recent studies show that CRS plus intraperitoneal chemotherapy applications confer prolonged survival in patients with PSM from colorectal, gastric, ovarian, appendiceal mucinous carcinoma and diffuse malignant peritoneal mesothelioma. The comprehensive treatment is now justified as state-of-the-art for patients with peritoneal metastasis.

Even though management of pseudomyxoma peritonei (PMP) was improved with cytoreductive surgery (CRS) and hyperthermic chemotherapy (HIPEC), several aspects of PMP still need to be optimized, including patient selection for surgery and prognostic factors. We assessed the role of preoperative carcinoembryonic antigen (CEA) levels in PMP patients treated with CRS and HIPEC.A total of 449 PMP patients with documented preoperative CEA levels referred to our center between 2005 and 2011 underwent CRS and HIPEC. The association between CEA levels and characteristics of patients with PMP was assessed with χ (2) test, linear correlation, and logistic regression analyses. Survival analysis was performed with Cox proportional hazard model.Median age was 55 (range 19-84) years. There were 245 (54.5 %) females and 204 (45.5 %) males. Preoperative CEA levels were elevated in 328 (73 %, sensitivity) patients with PMP. Preoperative CEA levels were also related to peritoneal cancer index (P0.0001), cytoreductive surgery scores (P0.0001), progress free survival (P0.001) and overall survival (P0.001) in patients with PMP.Our results indicated that preoperative CEA levels are useful in predicting the extent of disease and surgical success as well as progress-free and overall survival in patients with PMP treated with cytoreductive surgery and HIPEC.

The Peritoneal Cancer Index (PCI) is the most important prognostic factor following comprehensive treatment for peritoneal metastasis (PM) from gastric cancer (GCPM); however, 70 % of patients with GCPM showed a PCI score above the cut-off level at the time of diagnosis. Furthermore, neoadjuvant chemotherapy may reduce the PCI score to lower than the cut-off levels. In this study, the effects of neoadjuvant laparoscopic hyperthermic intraperitoneal chemoperfusion (NLHIPEC) and neoadjuvant intraperitoneal/systemic chemotherapy (NIPS) were investigated. In group A, NLHIPEC was performed twice in 53 patients with GCPM, separated by a 1-month rest interval. Changes in the PCI were studied at the time of first and second laparoscopy. In group B, after NLHIPEC, a series of 3-week cycles of NIPS were performed over three courses in 52 patients. A laparotomy for cytoreductive surgery (CRS) was then carried out and the PCI changes were studied. In group A, the PCI score at the time of the second session (11.8 ± 11.0) was significantly lower than at the time of the first session (14.2 ± 10.7), while in group B, the PCI at the time of laparotomy (9.9 ± 11.3) was significantly lower than at the time of NLHIPEC (14.8 ± 11.4). After NLHIPEC plus NIPS, complete cytoreduction was achieved in 30 (57.6 %) patients. NLHIPEC and NIPS are effective methods of reducing PCI levels before CRS.

Background and objective: The aim of this study is to analyze anatomical distribution, timing and outcomes of recurrence after complete cytoreduction and perioperative chemotherapy for peritoneal metastasis from gastric cancer (GCPM). Method: Data of 193 GCPM patients who underwent a complete cytoreductive surgery (CRS) after treatment with neoadjuvant chemotherapy were entered into a prospective database and the recurrence was analyzed. Result: The median time to progression was 16.2 months, median overall survival (OS) was 21.6 months and 5-year survival rate was 18.1%. Five years after CRS, 11 patients were disease free survivors. Recurrence rate was 68.5% (126/184). Mutivariate analysis confirmed small bowel peritoneal cancer index of ≥3 and pathologic nonresponders after NAC as independent risk factors for recurrence. Patients were treated with systemic chemotherapy or second cytoreductive surgery for recurrence. However, survival after diagnosis of recurrence was poor with median survival of 2.9 months. The most common type of recurrence was diffuse peritoneal recurrence (71%, 90/126). Localized intra-abdominal recurrence was experienced in only 7 patients. Conclusion: Pathologic non-responders and small bowel PCI of ≥3 are independent risk factors for recurrence. Exploratory laparoscopy after NAC might be a useful strategy for the selection of patients for CRS.

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/m(2) of Docetaxel and 30 mg/m(2) 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.

症例は70歳，男性．3日前より持続する右下腹部痛を主訴として外来受診した．血液検査データ上，炎症所見は高値を示し腹部造影CTにて軽度腫大した虫垂を認め，その周囲に隔壁を伴う液貯留がみられた．急性虫垂炎・虫垂周囲膿瘍と診断し，同日緊急手術を施行した．腹腔鏡で観察したところ，虫垂に表面平滑な腫瘤形成を認めた．周囲と癒着しており剥離する際に壁が破裂，白色膿汁が大量に流出した．腹腔鏡下では継続困難と判断し開腹，癒着剥離が困難であり回盲部切除術を施行した．摘出標本では直径約6cmの嚢胞の中央に虫垂様の構造物を認めた．病理組織学的検査では虫垂の嚢胞状拡張を認め，内腔には核腫大を示す上皮の乳頭状増殖を認めたが明らかな悪性所見は認めず膿瘍形成を伴う虫垂粘液嚢胞腺腫と診断された．術後2日目に上腸間膜静脈血栓症を発症するも保存的に改善し第35病日に退院となった．

Background. Photodynamic diagnosis (PDD) with 5-aminolevulinic acid (ALA) was used to detect peritoneal metastasis (PM). This study was done to verify the roles of the expressions of the peptide transporter PEPT1 and ATP-binding cassette transporter ABCG2 genes on the selection of patients in ALA PDD. Methods. The study group comprised 138 patients with PM. After oral administration of 5-ALA, PM was evaluated by PDD. Tissue protoporphyrin IX (PpIX) levels, and PEPT1/ABCG2 mRNA expressions were determined. Results. The tumor detection rate on PDD was 45.6% (63/138). PDD is a safe technique for the detection of PM from ovarian cancer, mesothelioma, and colorectal cancer. PpIX levels of ALA-PDD-positive PM were significantly higher than those of ALA-PDD-negative PM. The PpIX levels in PM that simultaneously expressed PEPT1 and ABCG2 mRNA were significantly higher than those in PM that expressed either PEPT1 or ABCG2 mRNA, as well as PM that expressed neither PEPT1 nor ABCG2 mRNA. PM with PEPT1 mRNA up-regulation showed simultaneous up-regulation of ABCG2 mRNA. PpIX accumulates in PM with PEPT1 up-regulation. At the same time, PpIX may be excreted into stromal tissue through ABCG2 transporter, resulting in the accumulation of excess PpIX in the stromal tissue near cancer cells. Conclusions. Preoperative evaluations of the expressions of the PEPT1 and ABCG2 genes by RT-PCR methods might facilitate the selection of patients most likely to benefit from ALA-PDD.Read Complete Article at ijSciences: V4201508802 AND DOI: http://dx.doi.org/10.18483/ijSci.802

The purpose of this manuscript is to report the pharmacokinetics of docetaxel during hyperthermic intraperitoneal chemotherapy (HIPEC) after peritonectomy.Eleven patients with peritoneal metastasis (PM) underwent peritonectomies combined with 40 min of HIPEC with 40 mg/body of docetaxel. The pharmacokinetics of docetaxel were studied by using high-performance liquid chromatography.The docetaxel concentration at the start of HIPEC (0 min) was 9.084 ± 0.972 mg/L. The concentration gradually decreased to 5.599 ± 0.458 mg/L 40 min after HIPEC. In contrast, serum docetaxel levels increased during HIPEC, reaching a maximum level of 0.1334 ± 0.0726 mg/L at 40 min. The clearance (CLp) was 3.164 ± 1.383 L/hr, and the area under the curve (AUC) ratio was 95.12 ± 87.32. The AUC ratio of less-extensive peritonectomies was significantly higher than that of extended peritonectomies. The docetaxel concentration in the tumor tissue increased at 40 min (4.45 mg/gr). The apparent permeability (Papp, 40 min) was 1.47 ± 0.67 mm/40 min. No severe adverse effects were observed after HIPEC.From these results, 40 mg is a safe dose for docetaxel combined with HIPEC, and the locoregional intensity of docetaxel is enough to control PM less than 1.47 mm in diameter.

Mechanisms of the Formation of Peritoneal Surface Malignancy on Omental Milky Spots from Low Grade Appendiceal Mucinous Carcinoma Purpose: Omental milky spot (OMS) is considered to have an important role in the formation of peritoneal surface malignancy (PSM). However, human OMS and cancer metastasis has not been fully clarified. The present study demonstrates the mechanisms of the formation of metastasis on the omental milky spots (OMS) from the low grade AMC. Methods and materials: To clarify the mechanism of the formation of peritoneal metastasis in low grade appendiceal mucinous carcinoma (AMC), 195 low grade AMC showing peritoneal cancer index (PCI) of ≤28 were studied for the distribution of peritoneal metastasis. Peritoneum was resected from 10 patients, and was prepared as whole-mount extending specimen. The specimens were studied by 5’-nucleotidase and alkaline phosphatase double stain and immunohistologic staining by D2-40, anti-CD31 and anti- Ki-67 monoclonal antibody. Furthermore, peritoneal parts were observed by scanning electron microscopy. Results: Pelvic and subdiaphragmatic peritoneum were involved in 164 (84%) and 143 (73%) patients. Greater omentum was involved in 135 (69%) patients. Under the SEM observation, no typical milky spots were observed on the peritoneum except for the greater omentum. Surface of OMS was covered with cuboidal mesothelial cells. Between the cuboidal mesothelial cells, many stomata were found. After digestion of OMS by 6N KOH, disk-like peritoneal pouch was detected at OMS. Small holes were found on the collagen plate covered on the bottom of the pouch. Below the pouch, initial lymphatic vessels closed to the pouch with stomata. Agglomerated blood capillaries distributed around the initial lymphatics. Metastasis foci were found around the stomata on OMS, but were not detected on the flat mesothelial cells on the greater omentum.. Conclusion: Peritoneal free cancer cells from low grade AMC may be adsorbed at stomata and adhere on the OMS. Then, they proliferate on OMS.

The past decade has greatly increased our understanding and appreciation of the ability of the central nervous system (CNS) to regulate food intake and body weight. This was spearheaded by the discovery of key molecules regulating body weight homeostasis. It is now also apparent that the CNS, especially the hypothalamus, plays a primary role in directly regulating glucose homeostasis, independently of effects on body weight. These discoveries are important given the increasing incidences of obesity and type II diabetes in Western societies. In this article, we will highlight recent data from genetically modified mice. These data and other models have helped to dissect the CNS pathways regulating body weight and glucose homeostasis. Finally, although these studies have been illustrative, they also underscore our relative lack of knowledge and highlight the need for more definitive approaches to unravel the functional significance of these pathways. J. Comp. Neurol. 493:63–71, 2005. © 2005 Wiley-Liss, Inc.

SummaryLeptin is required for normal energy and glucose homeostasis. The hypothalamic arcuate nucleus (ARH) has been proposed as an important site of leptin action. To assess the physiological significance of leptin signaling in the ARH, we used mice homozygous for a FLPe-reactivatable, leptin receptor null allele (Leprneo/neo mice). Similar to Leprdb/db mice, these mice are obese, hyperglycemic, hyperinsulinemic, infertile, and hypoactive. To selectively restore leptin signaling in the ARH, we generated an adeno-associated virus expressing FLPe-recombinase, which was delivered unilaterally into the hypothalamus using stereotaxic injections. We found that unilateral restoration of leptin signaling in the ARH of Leprneo/neo mice leads to a modest decrease in body weight and food intake. In contrast, unilateral reactivation markedly improved hyperinsulinemia and normalized blood glucose levels and locomotor activity. These data demonstrate that leptin signaling in the ARH is sufficient for mediating leptin’s effects on glucose homeostasis and locomotor activity.

Background: The purpose of this manuscript is to report the direct effects of hyperthermic intraperitoneal chemotherapy (HIPEC) in gastric cancer-patients with peritoneal metastasis (PM). Materials and Methods: Thirty-five patients with PM were enrolled, and were treated with neoadjuvant laparoscopic HIPEC (LHIPEC). LHIPEC was performed at 42 to 43 centigrade for 60 minutes adding 3 liter of saline plus 12.5mg/m2 of Mitomycin C with Cisplatin (50mg/m2). Second session of LHIPEC was done one month after the first LHIPEC in all cases. At the second session of LHIPEC, ascites volume, peritoneal cytology and peritoneal cancer index (PCI) were examined again. Results: Intraoperative complications of bowel injury were experienced in one and three at 1st and 2nd session of laparoscopy, respectively. There was no mortality after LHIPEC. Ascites was completely disappeared in 17 of 34 patients at the second session of laparoscopy. PFCCs had been detected in 28 (80.0%) patients at the 1st session, and the positive cytology changed to be negative in 16 (57.1%) of 28 patients at the second session. PCI at the 2nd session (12.5 ± 10.5) was significantly lower than that at the 1st session (16.8 ± 9.6) (P=0.023). PCI levels at the 2nd session changed to be 0 in 6 patients. Conclusion: This new method is not only a safe and convenient method for predicting feasibility of complete cytoredution, but also an effective treatment to control malignant ascites and to eradicate PFCCs before cytoreductive surgery. Furthermore, LHIPEC can reduce PCI levels.

Peritoneal dissemination is a frequent pattern of recurrence and metastasis of small bowel malignancy (SBM). However, the survival of patients with peritoneal dissemination from SBM is not clear, and there is no consensus on the treatment for it. A total of 31 selected patients with peritoneal dissemination from SBM were treated by cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) between January 2006 and January 2014. The major focus of this study was overall survival, as well as morbidity and mortality. Twenty-five patients had small bowel adenocarcinoma (SBA), and six patients had non-adenocarcinoma SBM. HIPEC was performed on 21 patients, and 21 patients received complete cytoreduction. There was no treatment-related mortality, and eight (25.8 %) patients had grade 3–4 complications. Until the latest follow-up, the median survival of 31 patients after CRS and HIPEC was 36 months (range 5–95 months), and the median survival after diagnosis was 51 months (range 18–101 months). For 25 patients with peritoneal carcinomatosis from SBA, the median survival after CRS and HIPEC was 36 months (range 6–95 months), and the median survival after diagnosis was 50 months (range 18–101 months). Multivariate analysis revealed that peritoneal cancer index

Pseudomyxoma peritonei (PMP) is a rare locoregional disease characterized by disseminated intraperitoneal mucinous tumors. However, little is known about PMP from urachal neoplasm as a result of its rarity.A total of 9 patients with PMP of urachal origin were treated by cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) in our institution. All specimens of surgeries were submitted for pathologic examination. Representative slides of tumors and normal urachus were submitted for immunohistochemical staining.Four patients were men; the median age was 48 years (range 27-65 years). Initial radiologic examination of all patients showed a cystic tumor located between posterior aspect of umbilicus and the dome of urinary bladder, with or without leaking mucin. Complete CRS and HIPEC were performed in all patients. Until the latest follow-up, local recurrence occurred in 1 patient. Other 8 patients had a median disease-free survival of 27.5 months. Primary urachal tumors of 9 cases were all mucinous adenocarcinoma. Six patients had low-grade mucinous carcinoma peritonei, and 3 patients had high-grade mucinous carcinoma peritonei. Signet ring cells were noted in 4 patients. All tumor specimens of 9 patients were diffuse positive for CK-20, CDX-2, MUC-2, and MUC-5AC, and were variant positive for CK-7.PMP arising from urachus comes from neoplastic cells with development of intestinal-type mucinous neoplasm. It shares a similar pathophysiology as PMP from appendix. CRS including total urethrectomy, partial cystectomy, and peritonectomy plus HIPEC can be considered as a new option of treatment for PMP originating from urachus.

Objective: Peritoneal Metastases (PM) of Gastric Cancer (GC) are lesions of peritoneal surfaces, which may cause the dissemination throughout the abdominal cavity. The role of laparoscopic Hyperthermic Intraperitoneal Chemotherapy (HIPEC) as neoadjuvant purpose in the management of PM of GC is undefined. Methods: Fifty patients were enrolled into this study with histopathological diagnosis of PM of GC referred to our center between 2012 and 2013 All patients were underwent two cycles of neoadjuvant laparoscopic HIPEC. At the second session of LHIPEC, ascites volume, cytological status and PCI levels were compared with those at the 1st LHIPEC. Results: There was no intraoperative complication and mortality after LHIPEC. Four patients developed mild azotemia of Grade 2. Amount of ascites were completely abolished or decreased in 22 of 34 (64.7%) and positive peritoneal cytology changed to be a negative in 14 of 20 (70%) patients at the 2nd LHIPEC. Complete response was in 6 (12%), and peritoneal cancer indices (PCI) were significantly reduced from 14.3 ± 10.2 at the 1st LHIPEC to 10.8 ± 10.5 at the 2nd LHIPEC (p

症例は59歳の女性.主訴は皮膚黄染.平成7年1月肝S4の肝細胞癌にて肝左葉切除術を施行.平成8年4月黄疸が出現, AFPの上昇も認めた.US, CTにて下部総胆管に径2cm大の円形の腫瘤影を認めた.平成8年5月開腹にて総胆管を切開, 腫瘤を摘出すると径2×3×3cmの表面平滑な茶褐色の腫瘍であり病理組織検査にて肝細胞癌と診断した.術後の胆管造影にて下部総胆管に陰影欠損を認め, また画像上残肝その他に肝細胞癌の再発を認めなかったため, 肝細胞癌が総胆管内に孤立性に転移したものと考え平成8年6月膵頭十二指腸切除術を施行した.切除標本では乳頭上約1cmの総胆管壁に腫瘍を認め, 総胆管の他の部位に病理組織学的に異常を認めなかった.この症例では肝癌細胞が胆汁内を浮遊し総胆管壁に着床したと推測されたが, 検索した範囲では文献上このような報告例はなく, 肝細胞癌の再発様式としては非常にまれと考えられたので報告す.

Management of peritoneal disseminated gastric cancer (GC) remains a challenging problem. The purpose of our study was to evaluate the outcome of bidirectional induction chemotherapy [bidirectional intraperitoneal and systemic induction chemotherapy (BIPSC)] in patients with peritoneal carcinomatosis (PC) arising from GC who underwent cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).Overall, 194 patients with PC arising from GC were treated with BIPSC comprising intraperitoneal docetaxel at a dose of 20 mg/m(2) and cisplatin at a dose of 30 mg/m(2) followed by four cycles of oral S-1 at a dose of 60 mg/m(2). CRS and HIPEC were performed in responders to BIPSC.Of these 194 patients, 152 (78.3 %) underwent CRS and HIPEC between January 2005 and December 2012. Treatment-related mortality was 3.9 %, and major complications occurred in 23.6 % of patients. The median survival rate was 15.8 months, with 1-, 2-, and 5-year survival rates of 66, 32 and 10.7 %, respectively, in the patients treated with combined treatment. Multivariate analysis identified pathologic response to BIPSC (p = 0.001), low tumor burden [peritoneal cancer index (PCI) ≤ 6] (p = 0.001), and completeness of CRS (CC-0, CC-1) (p = 0.001) as independent predictors for a better prognosis.As a viable option, BIPSC with CRS and HIPEC for patients with PC arising from GC may be performed safely, with acceptable morbidity and mortality, in a specialized unit. Response to BIPSC, optimal CRS and limited peritoneal dissemination seem to be essential to achieve the best outcomes in these patients.

肺瘻周囲の胸膜に子宮内膜間質様組織を認めた月経随伴性気胸の1例を経験した.症例は31歳の女性で, 月経時期に一致して右気胸を繰り返し発症していた.排卵抑制剤投与中は気胸の発症を認めなかったが, 投与中止後, 月経時期に一致して右気胸が再発した.開胸術時に, 右肺中葉に1mm大の肺瘻を認め, 肺部分切除術を行った.術後の病理組織検査で同肺瘻周囲の胸膜に子宮内膜間質様組織が認められ, 胸膜への子宮内膜組織の播腫が気胸の原因であると考えられた.肺胸膜に子宮内膜組織を認めた月経随伴性気胸の報告例は4例と非常に少数であり, 術中に肺瘻が確認された症例はそのうちの1例のみである.我々の症例は月経随伴性気胸の原因としての子宮内膜症胸腔内播腫説を裏付ける貴重な1例であり, 胸膜への小播腫巣を証明するためには気胸発症後できるだけ短い期間で胸腔鏡ないし開胸術を行う必要があると考えられた.

During the last 7 years, 21 patients with DMPM were treated. Histologic types were epitheloid type in 18 patients, biphasic type in 2 patients and sarcomatoid type in 1 patient. Preoperative systemic chemotherapy, hyperthermic intraperitoneal chemotherapy(HIPEC) by laparoscopy(LHIPEC), and intraperitoneal(IP) chemotherapy were done in 14, 3 and 1 patients, respectively. Cytoreductive surgery(CRS) was done in 13 patients. Ten patients received HIPEC after CRS. Partial responses were experienced in 4 of 13 patients treated with preoperative systemic chemotherapy. One of three patients treated by LHIPEC showed complete response. Among 13 patients received laparotomy, complete removal of PC was done in 4(31%) patients. The other 9 patients who received incomplete cytoreduction had diffuse involvement on the small bowel and its mesentery. All over 5-year survival was 17%. Patients treated with HIPEC survived significantly longer than non-HIPEC group. Neoadjuvant laparoscopic HIPEC may have a great role in the preoperative control of small PC on the surface of small bowel.

Background. Patients with early stage of pseudomyxoma peritonei (PMP) are sometimes difficult to diagnose the primary sites and intraperitoneal spread of tumor and to perform a cytological study.Methods. Patients without a definitive diagnosis and with unknown extent of peritoneal spread of tumor underwent laparoscopy. Hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) was administered as part of the same intervention. The results of treatment were evaluated at the time of second-look laparotomy (SLL) as a subsequent intervention.Results. Eleven patients were managed by diagnostic laparoscopy followed by laparoscopic HIPEC (LHIPEC). The operation time of laparoscopic examination and LHIPEC was 177 ± 26 min (range 124–261 min). No intraoperative complication was experienced. The peritoneal carcinomatosis index (PCI) score by laparoscopic observation was 16.5 ± 6.4 (range 0–30). One patient with localized pseudomyxoma peritonei (PMP) mucocele did not received LHIPEC; the other 10 patients with peritoneal metastases (PM) were treated with LHIPEC. After LHIPEC, ascites disappeared in 2 cases and decreased in the amount in the other 8 cases. Nine patients underwent SLL and cytoreductive surgery (CRS) combined with HIPEC. The duration between LHIPEC and SLL ranged from 40 to 207 days (97 ± 40 days). The PCI at the SLL ranged from 4 to 27 (12.9 ± 7.1). The PCI at the time of SLL decreased as compared to PCI at the time of diagnostic laparotomy in 7 of 9 patients. Median follow-up period is 22 months (range 7–35). All 11 patients are alive.Conclusion. The early results suggest that laparoscopic diagnosis combined with LHIPEC is useful to determine the surgical treatment plan and reduce the tumor burden before definitive CRS at SLL.

Background. Even though cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are associated with a high morbidity and mortality rates, it has been reported that CRS and HIPEC improved survival of selected patients with peritoneal carcinomatosis. We aimed to report morbidity and mortality results of CRS and HIPEC from a single institution in Japan.Methods and Results. Total of 284 procedures of CRS were performed on patients with pseudomyxoma peritonei, peritoneal carcinomatosis (PC) from colon cancer and gastric cancer between 2007 and 2011 in our institution. The morbidity rate was 49% of all procedure, and grades I/II and grades III/IV complications were 28% and 17%, respectively. Most frequent complication was surgical site infections including intraabdominal abscess. The mortality rate was 3.5%, and reoperation was needed in 11% of all procedures. Univariate and multivariate analysis showed peritoneal carcinomatosis index (PCI) greater than 20 was the only significant factor for occurrence of postoperative complications (P<0.01). In contrast, HIPEC significantly reduced postoperative complications (P<0.05).Conclusions. The morbidity and mortality rates of our institution are comparable with previous reports that are in acceptable rates. Optimal patient selection such as patients with PCI less than 20 seems to be of paramount importance to CRS and HIPEC.

A total of 521 patients with peritoneal carcinomatosis (PC) were treated by peritonectomy and perioperative chemotherapy. Each of the 95, 58, 316, 31, 10 and 11 patients were from gastric, colorectal, appendiceal, ovarian, small bowel cancer and mesothelioma, respectively. The distribution and volume of PC are recorded by the Sugarbaker peritoneal carcinomatosis index (PCI). Peritonectomy was performed with a radical resection of the primary tumor and all gross PC with involved organs, peritoneum, or tissue that was deemed technically feasible and safe for the patient. The postoperative major complication of grade 3 was found in 14%, and total 30-day mortality was 2.7%. The survival of gastric cancer patients with a PCI score ≤ 6 was significantly better than those with a PCI score ≥ 7. In appendiceal neoplasm, patients with PCI score less than 28 showed significantly better survival than those with PCI score greater than 29. The survival of colorectal cancer patients with a PCI score ≥ 11 was significantly poorer than those with a PCI score ≤ 10. Among the various prognostic factors in appendiceal neoplasm and gastric cancer patients, CC-0 complete cytoreduction was the most important independent prognostic factor. Peritonectomy is done to remove macroscopic disease and perioperative intraperitoneal chemotherapy to eradicate microscopic residual disease aiming to remove disease completely with a single procedure. Peritonectomy combined with perioperative chemotherapy may achieve long-term survival in a selected group of patients with PC. The higher mortality rate underlines this necessarily strict selection that should be reserved to experienced institutions.

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/m(2) of Docetaxel and 30 mg/m(2) 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 (P0.001). 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.