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Ida et al. J Cancer Metastasis Treat 2018;4:22  I  http://dx.doi.org/10.20517/2394-4722.2017.75                                    Page 5 of 9

               Table 2. Phase II clinical trials with intraperitoneal taxanes for gastric cancer with peritoneal disease
               Ref.                Year     No. of patients   1-year OS   MST (months)  Turned negative for cytology (%)
                         [21]
               Ishigami et al.     2010         40          78.0        22.6            24/28 (86)
               Fujiwara et al. [24]    2012     18          76.0        24.6            -
               Imano et al. [25]    2012        35          66.7        21.3            -
               Fushida et al. [26]    2013      27          70.4        16.2            18/22 (81.8)
               Yamaguchi et al. [27]    2013    35          77.1        17.6            28/29 (97)
               OS: overall survival; MST: median survival time

               Staging laparoscopy may be useful for the evaluation of resectability after chemotherapy. Several societies
               have  provided  recommendations  for  staging  laparoscopy  in  patients  with  advanced  gastric  cancer .
                                                                                                       [1,2]
               If information on the CY status is available prior to surgery, a chemotherapy-first strategy can be taken,
               whereby only patients whose cytology status turns negative are indicated for surgery. To verify the effect of
               preoperative chemotherapy on positive cytology, Jamel et al.  reviewed studies in which staging laparoscopy
                                                                 [28]
               was performed. Pooled analysis demonstrated that positive cytology was associated with significantly
               reduced OS (HR, 3.46; 95% CI, 2.77-4.31; P < 0.0001). Interestingly, negative cytology following neoadjuvant
               chemotherapy was associated with significantly improved OS (HR, 0.42; 95% CI, 0.31-0.57; P < 0.0001). The
               absence of macroscopic peritoneal disease with positive cytology was associated with significantly improved
               OS (HR, 0.64; 95% CI, 0.56-0.73; P < 0.0001). This study suggests that patients with initial positive cytology
               may have a good prognosis following neoadjuvant treatment if the cytology results become negative after
               treatment.

               Yoshida et al.  proposed new categories for the classification of stage IV gastric cancer that focused on
                           [29]
               the biology and heterogeneous characteristics of stage IV gastric cancer. They divided cancers based on
               the absence (categories 1 and 2) or presence (categories 3 and 4) of macroscopically detectable peritoneal
               dissemination, the biological outcome of which differs from that of hematological metastasis. Using this
               classification, Yamaguchi et al.  performed a retrospective study to clarify the role of conversion surgery
                                         [30]
               in the treatment of stage IV cancer. Even in patients with macroscopic peritoneal dissemination without
               other organ metastasis (category 3), the survival of those who underwent conversion surgery was prolonged
               (31.0 months), and even the MST of those who failed to undergo conversion surgery was relatively good (18.5
               months). However, patients with involvement of other organs in addition to peritoneal disease (classified as
               category 4; noncurable metastasis) understandably had fewer chances for surgical intervention, and their
               MST was 10 months.


               Postoperative complications
               Kubota  et  al.  reported that postoperative complications that cause prolonged inflammation have an
                           [31]
               obvious impact on not only OS but also disease-specific mortality of patients with gastric cancer, even if
               the tumor is curatively resected. Thus, when performing conversion surgery, it is necessary to perform safe
               gastrectomy that does not cause complications.


               Gastrectomy as conversion therapy can be safely conducted without perioperative mortality. The reported
               incidence of postoperative complications after gastrectomy is 24% to 29% [30,32] , which is similar to that in
               patients undergoing conventional radical surgery for gastric cancer (20.9% in patients with D2 lymph node
               dissection and 28.1% in patients undergoing an extended operation with aortic lymph node dissection)
               (JCOG9501) .
                         [33]
               Predictive factors for long-term outcome
               Several reports have described the long-term outcomes of conversion surgery for stage IV gastric cancer. In
               various studies, the prognosis of patients who underwent conversion surgery was significantly better than that
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