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Page 2 of 6                              Macedo et al. J Cancer Metastasis Treat 2018;4:8  I

               Keywords: Pressurized intraperitoneal aerosol chemotherapy, gastric cancer, peritoneal carcinomatosis

               Gastric cancer accounts for 6.8% of all cancers and it is the fifth most common cancer worldwide. Moreover,
               it is the third leading cause of death associated with cancer . Gastric cancer has three ways to spread through
               the body: neoplasic cells could use the lymphatic system to spread to the lymph nodes, the blood stream
               to spread to distant organs, and the dissemination to peritoneal cavity. This last type of spread is called
               peritoneal metastatization. Gastric cancer is the cancer with the highest rate of peritoneal metastization and
               this type of spread is associated with a higher death rate compared to distant organ metastasis . Without
               treatment, the median survival of these patients is 3-5 months.

               Gastrectomy combined with D2 lymph node dissection remains the standard of care to manage gastric cancer
               in advanced stages, however, peritoneal metastases still needs to be optimized. The systemic chemotherapy
               has a minimal effect in peritoneal metastasis because the barrier between blood and peritoneum do not
               allow a high concentration of drug in the peritoneum . An alternative to systemic chemotherapy consists
               in surgical removal of affected tissue combined with perioperative chemotherapy that includes: extensive
               intraoperative peritoneal lavage, neoadjucant intraperitoneal/systemic chemotherapy, hypertermic
               intraperitoneal chemotherapy (HIPEC), laparoscopic HIPEC and early postoperative intraperitoneal
               chemotherapy. The problems with these techniques are the need of complete cytoreduction in surgery and
               they are appropriate only for selected patients . Moreover, this treatment is hindered by significant risks and
               side effects with a 30-day mortality rate of 5% in referral centers .
               Recently, a new alternative therapy has emerged: pressurized intraperitoneal aerosol chemotherapy (PIPAC).
               This method can only be applied by laparoscopy and it is performed under general anesthesia. In this
               case, the chemotherapy is dispersed as pressurized aerosol into the peritoneal cavity by minimal invasive
               techniques, and left acting during 30 min. After this time, the gas is aspired. The recommendation is 3
               applications within 3 months. The most frequent adverse effects are fever, abdominal pain and nausea.
               Complications like infections, herniation or adhesion are uncommon due to minimally-invasive procedure
               [Figure 1].

               A PubMed search was conducted focusing on PIPAC in gastric cancer. The MeSH database was searched
               with the terms: “Gastric cancer [MeSH] and intraperitoneal aerosol chemotherapy”.

               A total of 5 articles were collected. One study was excluded because it is written in Chinese. Then, 3 articles
               were added because they were recent and pertinent. Ultimately, 7 studies were included in the analysis.

               The main results of the studies are listed in Table 1 [6-12] .

               Nadiradze et al.  demonstrated that PIPAC is well tolerated but has no effect in patients with synchronous
               malignant pleural effusion. Twenty-four patients were included in the study, and 60 PIPAC were performed:
               71% of the patients had repeated the procedure; no procedure-related mortality was reported; the mean
               survival time was 15.4 months; and objective tumor response was observed in 50% of the patients.

               Hübner et al.  had used as exclusion criteria for PIPAC the thrombosis of portal vein, intestinal occlusion
               and some clinical condition that could be a contra-indication for capnoperitoneum. Fifty-eight patients
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