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Role of CRS plus HIPEC in gastric cancer peritoneal carcinomatosis

Dear Editor, I read with interest the paper written by Rudloff U. entitled “Impact of Maximal Cytoreductive Surgery Plus Regional Heated Intraperitoneal Chemotherapy (HIPEC) on Outcome of Patients With Peritoneal Carcinomatosis of Gastric Origin: Results of the GYMSSA Trial” [1]. Peritoneal dissemination (PC) is the most frequent metastatic pattern in GC especially in diffuse Lauren histological subtype (most gastric cancer patients enrolled in this study have diffuse type GC). Traditionally, there is an agreementwithin the oncologist community that patients with gastric PC are incurable. Despite improvements in systemic chemotherapy, there have been no large phase III studies that demonstrated the real benefit of one regimen that could change PC prognosis. On the contrary, lately hyperthermic intraperitoneal chemotherapy (HIPEC) and cytoreductive surgery (CRS) reported encouraging survival results in treatment of GC PC. Recently, French surgeons collected data from 159 patients and it represents the largest experience of GC PC treatment with CRS and HIPEC [2]. This study shows that HIPEC survival results are less encouraging than those obtained for other peritoneal surface malignancies, reflecting a more aggressive disease less responsive to this multimodal treatment and thus the need for a better patient selection. However, the combination of CRS with HIPEC was the only therapeutic strategy that reported long‐term survivors at 5 years if a strictly patient selection was performed. CRS plus HIPEC obtains better survival results in a limited peritoneal cancer index (PCI) and if a complete cytoreduction (CC0) is achieved. Yang et al. [3], Yonemura et al. [4], and Fujimoto [5] also show similar results. Rudloff enrolled in the GYMS arm metastastic GC patients with a median PCI too high that needed an extensive surgery with an elevated complication and re‐operation rate and no real survival benefit. Probably, for this post‐surgical morbidity, only few patients were able to start adjuvant chemotherapy, useful in controlling the systemic disease. In addition, authors did not describe PCI distribution of patients enrolled in SA arm to better see survival effect of systemic chemotherapy against PC and to compare it to CRS and HIPEC procedure. Moreover, we do not understand why patients with a PCI1⁄4 0 underwent peritonectomies and HIPEC as illustrated in Table II. We agree with HIPEC associated to gastric resection and D2 lymphadenectomy, in positive peritoneal cytology, being it a IVth stage disease. We indeed sustain that aggressive CRS/HIPEC may be selectively offered to GC patients with low peritoneal tumor burden in whom CC0 can be achieved. CRS/HIPEC may be most beneficial in a prophylactic setting for patients with locally advancedGCwithout macroscopic PC and possibly those with positive peritoneal cytology or serosal invasion who are at high risk of developing PC.