52 Osp Ital Chir - Gennaio-Marzo 2008 The multimodal treatment of advanced-staged gastric cancer Background Gastric cancer in Western countries is often diagnosed in an ad- vanced or metastatic stage, with poor prognosis. Neoadjuvant chemotherapy (NAC) may improve both resectability and survival, but seems to be ineffective in reducing the risk of peritoneal recur- rence. Purpose To present a multimodal approach to advanced-stage gastric cancer by NAC, identifying potential chemo-responder patients by a basic 18F-FDG CT-PET scan, followed by radical surgery and hyperthermic intraperitoneal perfusion (HIPEC). Methods Twenty-four patients with T3-T4NX gastric cancer were en- rolled between March 2005 and February 2008; a basic 18F-FDG CT-PET scan was performed to identify potential chemo-responder patients, followed by staging laparoscopy and NAC (4 cycles of weekly PELF) for PET-positive patients. Patients with a reduction of the tumoral standard uptake value (SUV) greater than 35% after two cycles of NAC were considered metabolic responders to chemotherapy and completed therapy before surgery (radical D2 gastrectomy). In case of positive cytology/perigastric peritoneal nodules of carcinosis or gastric serosal infiltration a 60’ HIPEC (41.5-42.5°C) with a solution containing Cisplatin (25 mg/l/mq) and Mitomicin C (3.3 mg/l/mq) was performed. Ten patients com- pleted the neoadjuvant treatment: 1 patients refused surgery and 9 were operated on (HIPAC was associated in 8 patients). Results At semi-quantitative anatomic-pathological evaluation of the response to chemotherapy, 4 patients showed a sub-total or total re- gression of the tumoral mass, 2 showed partial regression, and 3 incomplete regression. Two of the 5 patients who were PET-nega- tive at the baseline scan died 3 and 6 months respectively after surgery and 2 had a follow-up of only 3 months. Of the 9 patients who completed treatment and were operated on, 2 died (1 after 9 months due to peritoneal carcinosis and 1 after 27 months due to recurrence of retro-peritoneal lymph node disease). The remaining 7 patients are still living. The patient who refused surgery died af- ter 4 months from progression of the disease. Conclusions In locally-advanced stage gastric cancer, a multi-modal ap- proach is to be preferred. R0 surgery is the main therapy, associat- ed with NAC whenever possible. FDG-PET could identify the re- sponders to chemotherapy and HIPEC in selected cases could re- duce the local and peritoneal recurrences. Key words: gastric cancer, neoadjuvant chemotherapy, HIPEC. La scarsa sopravvivenza per carcinoma gastrico nei Paesi occidentali è legata al fatto che esso si presenta spesso già in fase localmente avanzata o metastatica. La sopravvivenza a 5 anni è correlata allo stadio pTNM, con lo stadio linfonodale come principale fat- tore prognostico. STUDIO CLINICO Osp Ital Chir 2008; 14: 52-9 Il trattamento multimodale del cancro gastrico in fase avanzata Gianni Mura 1 , Davide Cavaliere 1 , Francesca Tauceri 1 , Luca Frassineti 2 , Massimo Framarini 1 , Alessio Vagliasindi 1 , Annamaria Marzullo 3 , Nicola Moles 1 , Giorgio Maria Verdecchia 1 Indirizzo per la corrispondenza: Dott. Gianni Mura Via Cimabue, 19 - 52100 Arezzo Tel.: 347-5595679 E-mail: gianmura@gmail.com 1 U.O. di Chirurgia e Terapie Oncologiche Avanzate Ospedale “Morgagni-Pierantoni” - Forlì 2 U.O. di Oncologia Medica Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori - Meldola (Forlì) 3 U.O. Semplice di Medicina Nucleare Ospedale “Morgagni-Pierantoni” - Forlì In collaborazione con il Coordinamento Scientifico Ospedale dei Pellegrini di Napoli