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Page 2 of 6 Macedo et al. J Cancer Metastasis Treat 2018;4:8 I http://dx.doi.org/10.20517/2394-4722.2017.72

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

INTRODUCTION
Gastric cancer accounts for 6.8% of all cancers and it is the fifth most common cancer worldwide. Moreover,
[1]
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
[2]
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
[3]
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
[4]
they are appropriate only for selected patients . Moreover, this treatment is hindered by significant risks and
[5]
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].

METHODS
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.

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

[6]
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.

[7]
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