Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) in Gastric Cancer Patients with Peritoneal Metastasis (PM): Results of a Single-Center Experience and Register Study

Abstract

Purpose: Gastric cancer (GC) patients with peritoneal metastasis (PM) have poor prognosis. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) in combination with systemic chemotherapy is a novel treatment option for patients in stage IV of the disease.

Materials and methods: Between November 2015 and June 2018, prospective data collection was performed in 24 patients with GC and PM (median age, 57; range, 44-75 years). These patients underwent 46 PIPAC procedures with a median number of 2 interventions per patient (range, 1-6). A laparoscopic access was used and a combined therapy of cisplatin and doxorubicin aerosol was administered.

Results: The median peritoneal carcinomatosis index before the 1st PIPAC was 14 (range, 2-36), and the median ascites volume in patients before the 1st PIPAC was 100 mL (range, 0-6 mL, 300 mL). Eleven patients, who received 2 or more PIPAC procedures, had decreased and stable volumes of ascites, while only 3 patients displayed increasing volume of ascites. The median overall survival was 121 days (range, 66-625 days) after the 1st PIPAC procedure, while 8 patients who received more than 3 PIPAC procedures had a median survival of 450 days (range, 206-481 days) (P=0.0376).

Conclusions: Our data show that PIPAC is safe and well tolerated, and that the production of ascites can be controlled by PIPAC in GC patients. Patients, who received 2 or more PIPAC procedures, reported a stable overall quality of life. Further studies are required to document the significance of PIPAC as a palliative multimodal therapy.

Trial registration: ClinicalTrials.gov Identifier: NCT03100708.

Keywords: Gastric cancer; PIPAC; Palliative chemotherapy; Peritoneal metastasis.

Conflict of interest statement

Conflict of Interest: No potential conflict of interest relevant to this article was reported.

Figures

Fig. 1. Flow chart of patient inclusion and PIPAC procedures. 28 patients were eligible for PIPAC with 52 scheduled PIPAC procedures. Because of 1 aspiration and 5 “non-access” abdomens, 24 patients received 46 PIPAC procedures.

PIPAC = pressurized intraperitoneal aerosol chemotherapy.

Fig. 2. PCI and tumor cell portion developments in patients with multiple PIPAC procedures. (A) Number of patients with decreased, stable, and increased PCI, (B) Number of patients with decreased, stable, and increased tumor cell portions in PM biopsies, and (C) representative H&E staining of patients with decreased tumor cell portions (patients No. 10 and No. 13) and increased tumor cell portions (patients No. 3 and No. 9). The biopsies for tumor cell evaluation were taken before each PIPAC.

PCI = peritoneal carcinomatosis index; PIPAC = pressurized intraperitoneal aerosol chemotherapy; PM = peritoneal metastasis; H&E = hematoxylin and eosin stain.

Fig. 3. Relative ascites development in patients with multiple PIPAC procedures. The fold changes of decreased (6), stable (5), and increased (3) ascites volumes during multiple PIPAC procedures are blotted as waterfall blot.

PIPAC = pressurized intraperitoneal aerosol chemotherapy.

Fig. 4. Survival curves. (A) Kaplan-Meier survival curves of all 24 patients treated by PIPAC, (B) stratification of patients, who received 1 or 2 PIPACs (16) vs. 3 or more PIPACs (8; P=0.0376), (C) metachronous (6) vs. synchronous (18) PM, and (D) diffuse (19) vs. intestinal (5) type of GC according to Laurén's classification (Log-Rank [Mantel-Cox] test).

PIPAC = pressurized intraperitoneal aerosol chemotherapy; PM = peritoneal metastasis; GC = gastric cancer.