5-Fluorouracil, methotrexate, leucovorin, CDDP and epirubicin (FEPMTX): a wide-spectrum regimen of salvage chemotherapy for high-grade advanced gastric cancer.

BACKGROUND/AIMS: Twenty-one patients with primary stage IV gastric cancer were treated with a wide-spectrum regimen, designated as FEPMTX therapy to establish an effective salvage chemotherapy. METHODOLOGY: FEPMTX therapy consisted of 5-fluorouracil and the triple biochemical modulators in addition to epirubicin. The schedule comprised 3 days continuous administration of 5-fluorouracil (350 mg/m2/day) and; methotrexate (MTX; 35 mg/m2) on day 1, calcium leucovorin (LV; 30 mg/m2) on day 2 and 3, cisplatin (CDDP; 30 mg/m2) and epirubicin (20 mg/m2) on day 3 every 2 weeks in principle. RESULTS: Eleven partial responses, five no changes and five progressive diseases were obtained, and the response rate was 52%. Ten patients (partial response 7, no change 2, progressive disease 1) received gastrectomy (resectability rate 48%). The survival of responders was significantly longer than that of non-responders (median survival time, 356 days vs. 152 days) while there was no significant prolongation by resection of the primary lesion. Adverse effects such as myelosuppression, anorexia and fatigue sometimes occurred, but were mild and the regimen was well tolerated by all the patients. CONCLUSIONS: FEPMTX is thought to be an effective regimen for neoadjuvant chemotherapy with longer survival and little toxicity for patients with high-grade advanced gastric cancer.

[Significance of peritonectomy for peritonitis carcinomatosis].

We analyzed patients who underwent multimodal treatment with peritonectomy as an aggressive treatment for peritonitis carcinomatosis. Peritonectomy was treated in eighteen cases (eleven gastric cancer, seven colon cancer). Out of these eighteen cases, nine were initial operation, six were recurrence after first operation and three were for relief after palliative operation for peritoneal dissemination. Five cases of recurrence included ileus. Of all eighteen patients, ten had received preoperative chemotherapies. Peritonectomy made complete resection possible principle, and the procedure included resection of the primary lesion, subtotal colectomy and peritonectomy. An intestinal stoma was needed in nine cases, consequently. All patients cases underwent continuous hyperthermic peritoneal perfusion (CHPP). Early postoperative peritoneal chemotherapy was given in five cases. By peritonectomy for a first time operation, macroscopically complete resection was possible in six cases. In relief and recurrence cases few tumor cells remained in five cases. Ileus due to peritoneal carcinomatosia was eliminated in all cases, and caloric intake became possible. Fourteen cases had postoperative complication (morbidity 78%), and treatment-related death occurred in three cases (mortality 17%). It became possible to resect even the peritoneal dissemination that was inoperable by conventional surgery, and improvement of QOL was achieved by peritonectomy in cases of carcinomatous peritonitis. However, postoperative care is important since aggression becomes more intense.

[Multidisciplinary therapy for peritoneal dissemination using peritonectomy].

An aggressive approach to peritoneal dissemination involves peritonectomy procedures combined with preoperative intraperitoneal chemotherapy, intraoperative chemo-hyperthermia, and postoperative systemic chemotherapy. We have been performing multimodal therapy consisting of peritonectomy plus perioperative chemotherapy for the treatment of patients with peritoneal dissemination. Fifty-seven patients with established peritoneal dissemination from gastric cancer (n = 32), colon cancer (n = 17), ovarian cancer (n = 7), and mesothelioma (n = 1) have been treated with peritonectomy and intraoperative chemo-hyperthermia. Five-year survival rates of patients with gastric and colon cancer were 18% and 38%, respectively. Among various clinical factors, complete tumor resection was the most significant prognostic factor, and the prognosis of patients who underwent complete cytoreduction was significantly better than those who received incomplete cytoreduction. A multimodal therapy consisting of perioperative chemotherapy and peritonectomy with complete cytoreduction may be the most powerful method to treat patients with established peritoneal dissemination.