Author: Gastric Cancer Committee of Chinese Anti-Cancer Association
Source: Chinese Journal of Gastrointestinal Surgery, 2023, 26(8)
summary
The mainland is a country with a high incidence of gastric cancer, and it is dominated by patients in the middle and advanced stages. The peritoneum is the most common site of metastasis and recurrence of advanced gastric cancer. Paying attention to the standardized diagnosis and treatment of peritoneal metastasis of gastric cancer is expected to significantly improve the prognosis and quality of life of some patients. Based on evidence-based medical evidence and the internationally accepted Delphi method, this consensus revises the Chinese Expert Consensus on the Prevention and Treatment of Peritoneal Metastasis of Gastric Cancer (2017 Edition), and reaches a preliminary consensus on the definition, classification, high-risk factors, diagnosis and prediction, degree assessment, prevention, treatment and complication treatment of gastric cancer, so as to provide guidance for clinical work.
Gastric cancer is a common malignant tumor of the digestive tract in mainland China, and its incidence and mortality rank third among malignant tumors. Early stage gastric cancer accounts for only about 20% of patients in mainland China, mainly in the middle and advanced stages. The peritoneum is the most common site of recurrence and metastasis of advanced gastric cancer, and according to epidemiological survey data, the number of cases of peritoneal metastasis of gastric cancer in mainland China reached 523 937 in 2020. About 20% of patients were diagnosed with peritoneal metastasis before or during surgery, more than 50% of patients with T3 and T4 stages had peritoneal metastasis after radical resection, and the median survival time of advanced patients with peritoneal metastasis was only 3~6 months, and the 5-year survival rate was less than 2%. Peritoneal metastasis has different characteristics from metastasis of other organs, and can cause specific complications such as ascites and malignant intestinal obstruction. Before the 90s of the 20th century, peritoneal metastasis of gastric cancer was considered to be the terminal stage of ineffective treatment, and only palliative symptomatic treatment was usually required, while systemic therapy was extremely ineffective for peritoneal metastasis. With the deepening of research, the innovation and improvement of new drugs and treatment technologies, and the introduction of translational treatment concepts, the prognosis of some patients has been significantly improved, which has also aroused the attention of clinicians to the early diagnosis of peritoneal metastasis and the improvement of related treatment options. At present, the degree of peritoneal metastasis of gastric cancer is evaluated by the peritoneal cancer index (PCI), followed by the intervention of surgery combined with intraperitoneal chemotherapy, hyperthermic intraperitoneal chemotherapy (HIPEC), systemic chemotherapy, targeted therapy and immunotherapy, which is expected to improve the prognosis of some patients with peritoneal metastasis. In order to standardize the diagnosis and treatment of peritoneal metastasis of gastric cancer, the Gastric Cancer Professional Committee of the Chinese Anti-Cancer Association organized authoritative experts in the field of gastric cancer in China to compile the "Chinese Expert Consensus on the Prevention and Treatment of Peritoneal Metastasis of Gastric Cancer (2017)" as early as 2017. In view of the research progress of peritoneal metastasis of gastric cancer in the past six years, the Gastric Cancer Professional Committee of the Chinese Anti-Cancer Association organized domestic multidisciplinary experts to update the 2017 version of the consensus, and after repeated discussions and revisions, the Chinese Expert Consensus on the Diagnosis and Treatment of Gastric Cancer Peritoneal Metastasis (2023 Edition) was compiled, hereinafter referred to as the consensus. This consensus includes the definition, classification, high-risk influencing factors, diagnosis and prediction of peritoneal metastasis, assessment and recording of the degree of peritoneal metastasis, prevention, treatment and complication management of gastric cancer Evaluation) grading criteria, the evidence is graded, see Table 1, and the internationally accepted Delphi method is used to organize expert voting to revise and reach relevant recommendations. The voting was divided into 6 levels: full agreement (100%), basic agreement (80%), partial agreement (60%), partial disagreement (40%), more opposition (20%) and complete disagreement (0), resulting in a total of 21 recommendations. The recommendation level is divided into two levels of strong recommendation and weak recommendation according to the expert vote: the number of votes voted "fully agree" exceeds 80%, which is a strong recommendation, and the number of votes of "completely agree" + "basic agreement" exceeds 80%, which is a weak recommendation.
1. Definition of peritoneal metastasis of gastric cancer
Recommendation 1: Peritoneal metastasis of gastric cancer refers to the form of cancer metastasis caused by the primary cancer cells of gastric cancer through peritoneal implantation and other pathways. (Quality of evidence: moderate; level of recommendation: strong; panel approval rate: 98.6%)
The seed-soil theory was first proposed by Paget in 1989 and is considered to be the most important hypothesis of peritoneal metastasis. According to this theory, peritoneal metastasis is a multi-stage and multifactorial process. It mainly includes: (1) cancer cells break through the serous membrane and fall off into the abdominal cavity, (2) cancer cells adhere to the peritoneum, and (3) cancer cells invade the peritoneum, promote the formation of peripheral neovascularization, and develop into metastases. Essentially, peritoneal metastasis is a process of cell migration, adhesion, invasion, and angiogenesis. There are two main sources of peritoneal free cancer cells: (1) the natural detachment of the tumor through the serous membrane during the invasion and growth process, and (2) the iatrogenic dissemination caused by the surgical process. Intraoperative squeezing and stretching of tumors can cause iatrogenic peritoneal implant metastasis, which should be paid attention to by clinical surgeons. Free cancer cells form peritoneal metastases mainly through the mesothelial cell pathway and the lymphatic porous pathway. In addition, some scholars speculate that there is a possibility of hematogenous and lymphatic metastasis in peritoneal metastasis. Recommendation 2: Peritoneal metastases that are not found by standardized preoperative imaging and are diagnosed intraoperatively are called clinically occult peritoneal metastases. (Quality of evidence: low; level of recommendation: strong recommendation; panel approval rate: 97.7%) Thin-slice contrast-enhanced CT is the most commonly used preoperative test for peritoneal metastases. Although CT has a high specificity for the diagnosis of peritoneal metastasis, the sensitivity is only about 50%, and 10%~30% of preoperative CT examinations diagnose advanced gastric cancer without peritoneal metastasis, and peritoneal metastasis is found during intraoperative exploration. This part of the peritoneal metastasis that is not found on imaging and confirmed by intraoperative exploration is defined as clinically occult peritoneal metastases. The diagnosis of peritoneal metastasis by imaging is affected to some extent by the experience and recognition ability of the diagnostician. Researchers at home and abroad have tried to improve the detection rate of occult peritoneal metastasis by using non-invasive detection methods, combined with clinical indicators, hematological test indicators and molecular markers, and using nomograms or artificial intelligence. Laparoscopic exploration is the diagnostic tool for peritoneal metastases. Recommendation 3: Positive peritoneal lavage cytology (P0CY1) is defined as distant metastases (M1). (Quality of evidence: high; level of recommendation: strong recommendation; panel approval rate: 98.2%) Patients with positive peritoneal lavage cytology have a poor prognosis, with a 5-year survival rate of 10%~26%, a recurrence-free survival rate of 21%, a median survival of 16 months, a high recurrence rate after surgery, and P0CY1 is considered a manifestation of metastatic disease requiring systemic chemotherapy. The American Joint Committee on Cancer (AJCC) gastric cancer staging defines P0CY1 as distant metastases (M1), and both CY1 and peritoneal metastases P1 are stage IV gastric cancers. However, P0CY1, as a special subpopulation, has a better prognosis than extensively metastatic stage IV gastric cancer. Patients with P0CY1 who received systemic chemotherapy and were cytologically negative (P0CY0) by laparoscopic staging showed a significant improvement in disease-free survival. Therefore, targeted identification and treatment can help improve the prognosis of patients with P0CY1.
2. Classification of peritoneal metastasis of gastric cancer
Recommendation 4: Peritoneal metastases can be divided into P0CY1, P1a, P1b, and P1c, which are combined with PCI scores to assess the extent and location of metastases. (Quality of evidence: moderate; level of recommendation: strong; panel approval rate: 95.9%)
Detailed classification helps to make treatment more precise. Refer to the classification of the Japanese Society of Gastric Cancer: (1) PX, which means that it is impossible to determine whether there is peritoneal metastasis. (2) P0, refers to the absence of peritoneal metastasis. (3) P1, which refers to peritoneal metastases, can be further divided into P1a, P1b and P1c. P1a is localized peritoneal metastases (confined to the peritoneum near the stomach, omentum, omentum, anterior transverse colon membrane, pancreatic tuning, and spleen). P1b metastasizes to the upper abdomen, and P1c metastasizes to the middle and lower abdomen. It is worth emphasizing that P1a, P1b, and P1c may coexist, and should be carefully explored during surgery, such as if the tumor is located in the posterior wall of the stomach, to explore whether it has penetrated the serous membrane and involved adjacent structures, and the gastrocolic ligament needs to be opened to explore whether the transverse mesocolon and pancreatic tunic have been invaded. The left lateral lobe of the liver was lifted to expose the side of the lesser curvature of the stomach to observe whether the tumor had penetrated the serous membrane and the omentum was involved, and the degree and location of metastasis should be evaluated in combination with PCI score. In addition, P0CY1 needs to be classified separately (see recommendation 3) for more targeted treatment.
3. Risk factors for peritoneal metastasis of gastric cancer
Recommendation 5: Risk factors for peritoneal metastasis of gastric cancer include T3, T4 stage, lymph node metastasis (N+), extranodal invasion, Borrmann type IV., Lauren classification diffuse, signet ring cell carcinoma, tumor perforation or rupture, etc. (Quality of evidence: high; level of recommendation: strong; panel approval rate: 99.1%)
Peritoneal metastasis or recurrence of gastric cancer is related to tumor stage and pathological type, and high peritoneal metastasis rate is related to high T stage, especially T4 stage, degree of lymph node metastasis, Borrmann classification and pathological type of undifferentiated carcinoma. Borrmann IV has a 2.06-fold higher risk of metastasis than other types, and the Lauren type diffuse has a peritoneal metastasis risk of more than 80%. The incidence of peritoneal metastasis in patients with T3 or T4 stage and N+ was 25%, and the incidence of peritoneal metastasis in patients with positive lymph nodes was 3.84 times that of patients with negative patients, and the risk of peritoneal metastasis was higher in patients with extranodal metastasis. In addition, tumor perforation or rupture, signet ring cell carcinoma, mucinous adenocarcinoma, and poorly differentiated pathological type are all risk factors for peritoneal metastasis.
4. Diagnosis and prediction of peritoneal metastasis of gastric cancer
Recommendation 6: Thin-slice CT of the abdomen (abdominal cavity + pelvis) is the preferred imaging examination method for peritoneal metastasis of gastric cancer. (Quality of evidence: high; level of recommendation: strong; panel approval rate: 97.7%)
Thin-slice enhanced CT has a sensitivity of 50% and a specificity of 95%~99% in the diagnosis of peritoneal metastasis of gastric cancer, which is better than ultrasound and PET-CT examination, and multiplanar CT reconstruction is helpful to clarify the location and distribution of peritoneal metastasis. Typical signs of peritoneal metastasis of gastric cancer include uneven peritoneal thickening, hyperenhancement, or nodules, multiple cords and nodules of the omentum or omentum, nodular thickening of the mesentery, direct signs of abdominopelvic effusion, and indirect signs of dilation of the bile ducts, ureters, and bowels. The detection performance of PET-CT depends on the uptake rate of 18F fluorodeoxyglucose (FDG) by cancer cells, which is related to glucose transporter-1 (GLUT1) expression. The expression of GLUT1 in different gastric cancer tissues varies greatly. Signet ring cell carcinoma, mucinous adenocarcinoma, or poorly differentiated adenocarcinoma are the most common histological types of peritoneal metastases, and GLUT1 has a very low positive expression rate in these tissue types. The use of fibroblast activating protein inhibitor (FAPI) as a novel metabolic contrast agent for PET-CT is helpful to improve the diagnostic rate of peritoneal metastasis of gastric cancer. MRI may be used as an alternative in patients where contrast-enhanced CT is contraindicated. Ascites was detected by imaging to be more than 50 ml, and the positive rate of peritoneal metastasis was 75%~100%. After peritoneal metastasis of gastric cancer, tumor markers such as carcinoembryonic antigen (CEA), glycochain protein (CA) 125, CA19-9 and CA724 in serum can be increased, but the sensitivity and positive predictive value for diagnosing peritoneal metastasis of gastric cancer are poor, and the sensitivity and specificity of the combined detection of multiple markers will be improved. However, the detection of serum tumor markers alone cannot be used as a basis for the diagnosis of peritoneal metastasis. The combination of clinical indicators and preoperative serological tests CA125 and CA724 can be of certain value in improving the detection rate of peritoneal metastasis. The results showed that the peritoneal CT image characteristics of the tumor and its vicinity were related to peritoneal metastasis (P<0.05), and the sensitivity of the joint diagnostic model was more than 90%, which significantly improved the detection rate of occult peritoneal metastasis.
Recommendation 7: Diagnostic laparoscopy + abdominal cytology + peritoneal nodule biopsy is the most reliable means to diagnose suspicious peritoneal metastases and assess the degree of peritoneal metastases, which is helpful for clinical decision-making. (Quality of evidence: high; level of recommendation: strong; panel approval rate: 100%)
Diagnostic laparoscopy + abdominal cytology + biopsy of peritoneal nodules is the most reliable way to stage the peritoneum. In particular, the sensitivity and specificity of the detection of clinically occult peritoneal metastases are high, and the peritoneal cancer index (PCI) score and neoadjuvant therapy response can be accurately evaluated. Cohort studies including gastric cancer of all stages showed that 14%~17% of patients could find macroscopic peritoneal metastases at the same time, and up to 41% of patients had positive cytology. It has been reported in the literature that the sensitivity of peritoneal cytology for the detection of occult peritoneal metastasis is 26%~70.8%, and these differences may be related to the non-standard cell irrigation operation and the limitation of cytopathological detection methods. The results of diagnostic laparoscopy + abdominal cytology + peritoneal nodule biopsy are helpful for clinical treatment decisions. In a prospective study in Japan, 156 asymptomatic patients with histological Borrmann type III or IV, or enlarged lymph nodes on imaging were applied, and laparoscopic exploration + cytology was used, and the results showed that 47% of patients changed their initial treatment strategy due to the discovery of occult peritoneal metastases.
5. Assessment and recording of the degree of peritoneal metastasis
Recommendation 8: Laparoscopic staging + examination of peritoneal free cancer cells and peritoneal nodule biopsy should be performed for patients with clinical stage cT3 or cT4 and high-risk factors for peritoneal metastasis, and peritoneal nodule biopsy if necessary (quality of evidence: moderate; recommendation level: strong recommendation; expert group approval rate: 98.2%)
Laparoscopic staging is recommended for patients with clinical stages cT3 and cT4 and high-risk factors for peritoneal metastasis. Cytology is a key component of laparoscopic exploration staging, with 13% of patients with laparoscopic exploration without obvious macroscopic peritoneal metastases having positive cytology (CY1). Ascites or peritoneal lavage fluid cytology is currently the gold standard for diagnosing cell-free cancer cells in the abdominal cavity. During peritoneal lavage, > 250 ml of normal saline can be injected into the peritoneal cavity, aspirated and sent for cytopathological analysis to determine the presence of free cancer cells. It is important to note that lavage negative (CY0) has the potential for false negatives and is not fully representative of tumor biological behavior, and peritoneal recurrence occurs in 29% of CY0 patients after resection of the primary tumor R0. For indeterminate peritoneal nodules, pathological biopsy can be used to assist in diagnosis.
Recommendation 9: Standardize the operation process of abdominal free cancer cell examination, including the sequence of irrigation, collect sufficient ascites or irrigation fluid, and send it for staining in time to improve the detection rate. (Quality of evidence: moderate; level of recommendation: strong; panel approval rate: 99.5%)
The examination of free cancer cells in the abdominal cavity is difficult and the detection rate is low, and multiple links from surgical operation to pathological testing may affect the test results. It is recommended to follow the standard operation of peritoneal cytology irrigation: (1) Lavage fluid collection: It is recommended to rinse with > 250 ml of warm normal saline in a certain order, avoid direct irrigation of the primary lesion, and pay attention to protecting the serous surface. The irrigation sequence can be from bilateral diaphragm, suprahepatic, subhepatic, omentum, bilateral paracolic gutter to uterine-vesicorectal fovea, and > 100 ml of lavage fluid can be collected in bilateral subdiaphragmatic area, subhepatic area, and Douglas fossa. If there is an adequate amount of ascites (>200 mL), it can also be taken directly for testing. (2) Cytology detection: After collecting ascites or intraperitoneal irrigation fluid, send it to the pathology department for staining and microscopic examination as soon as possible, and feedback the results to the surgeon in time for clinical decision-making.
Recommendation 10: Peritoneal cancer index (PCI) score assesses the degree of peritoneal metastasis. (Quality of evidence: moderate; level of recommendation: strong; panel approval rate: 99.5%)
As early as 1996, Jacquet and Sugarbaker proposed to use PCI to evaluate the degree of peritoneal metastasis, which divides the abdominal cavity into 9 divisions and the small intestine into 4 divisions, a total of 13 divisions, and each partition is assigned a score of 0~3 according to the lesion size (LS) seen during surgery, which is widely used in the evaluation of peritoneal cancer. Intraoperatively, 13 partitions were examined, and the LS score of each partition was determined, with a total score of 39 points, to evaluate the distribution of peritoneal tumors. However, PCI evaluation is difficult in practice, and its accuracy and operability need to be studied.
Recommendation 11: The completeness of cytoreduction (CC) score assesses the degree of tumor residual after cytoreductive surgery (CRS). (Quality of evidence: moderate; level of recommendation: strong; panel approval rate: 98.2%)
In 1996, Jacquet and Sugarbaker proposed the use of the completeness of cytoreduction (CC) score to assess the degree of tumor residual after CRS. CC-0: no peritoneal nodules were visible after CRS, CC-1: residual tumor nodules <2.5 mm, CC-2: residual tumor nodules between 2.5 mm~2.5 cm, CC-3: residual tumor nodules > 2.5 cm, or residual unresectable tumor nodules or confluent lesions in the abdominopelvic cavity. CC-2 and CC-3 are incomplete CRS. At present, although CC scoring is widely used, it is still very difficult to make an accurate assessment in practical application, and further refinement is needed to improve its accuracy and reliability. It is recommended to quantitatively evaluate and register the degree of intraoperative peritoneal metastasis and residual tumors after CRS, so as to facilitate precision treatment, clinical research and experience summarization.
6. Prevention of peritoneal metastasis of gastric cancer
Recommendation 12: Strict tumor-free operation during surgery to prevent iatrogenic peritoneal spread and metastasis. (Quality of evidence: high; level of recommendation: strong, panel approval rate: 99.5%)
Specific preventive measures: (1) pay attention to the protection of the inclement, it is recommended to use the incision protector to prevent incision contamination or tumor implantation, etc.; (2) avoid direct contact and squeezing of the tumor during the operation, if the tumor leaches out of the serous layer, pay attention to the use of gauze or surgical film to cover the tumor to prevent spread; (3) replace the gloves and surgical instruments contaminated by the tumor in time during the operation; (4) replace the blood swab gauze in time, try not to use it repeatedly, and do not take out the gauze contaminated during laparoscopic surgery directly from the poke hole; (5) thoroughly rinse the abdominal cavity with warm distilled water or normal saline after the operation; (6) pay attention to the wound before closing the abdomen; (7) pay attention to the indications of laparoscopic surgery(8) At the end of laparoscopic surgery, attention should be paid to exclude pneumoperitoneum to prevent poke or incision tumor implantation, and (9) open surgery should be selected for CRS.
Recommendation 13: For patients at high risk of peritoneal metastases, intraoperative or early postoperative prophylactic intraperitoneal chemotherapy (including HIPEC and normothermic intraperitoneal chemotherapy (NIPEC) may be considered. (Quality of evidence: moderate; level of recommendation: strong recommendation, panel approval rate: 98.2%)
In recent years, a number of studies have shown that intraoperative and/or early postoperative intraperitoneal chemotherapy as a preventive treatment for patients with advanced gastric cancer can reduce the recurrence rate of peritoneal metastasis and improve the survival rate of patients. HIPEC is the earliest reported intraperitoneal infusion administration, and NIPEC has the advantages of convenient medication, so it is recommended that clinicians choose feasible treatment measures according to actual conditions. Professor Liang Han's team reported that prophylactic HIPEC for locally advanced gastric cancer after D2 radical resection can significantly improve the 5-year survival rate of patients with stage III (7th version TNM stage), and the improvement of the 5-year survival rate of stage III.B patients is statistically significant (40.9% vs. 27.3%, P=0.046). Type IV locally advanced gastric cancer could significantly improve the 5-year survival rate of patients (P<0.05). Prophylactic HIPEC is safe and reliable, can prevent peritoneal recurrence and prolong survival, but there is still a need for well-designed clinical studies that meet the current treatment standards, and prophylactic HIPEC is not currently used as a routine recommended treatment for advanced gastric cancer after surgery. STUDIES SUCH AS GASTRICHIP (NCT01882933) AND PREVENT (NCT04447352) ARE STILL ONGOING, BUT IT IS UNDERSTOOD THAT THE GASTRICHIP STUDY FROM FRANCE HAS NOT PROGRESSED SMOOTHLY FOR 8 YEARS SINCE ITS LAUNCH IN 2014, AND NO RESULTS HAVE BEEN REPORTED SO FAR. In 2019, 648 patients were enrolled in the prospective, multicenter, randomized controlled, phase III study of adjuvant HIPEC after D2 radical resection of locally advanced gastric cancer (HIPEC-01 study: NCT02356276) led by Professor Cui Shushu, and the results of the 3-year follow-up will be announced in the near future.
7. Treatment of peritoneal metastasis of gastric cancer
(1) Systemic treatment
Recommendation 14: Systemic treatment refers to the treatment of metastatic gastric cancer, including chemotherapy, immunotherapy, and targeted therapy. (Quality of evidence: high; level of recommendation: strong, panel approval rate: 96.8%)
1. The main chemotherapy regimens in the first line of chemotherapy include XELOX (3 weeks/course of treatment): oxaliplatin 130 mg/m2 intravenous drip d1, capecitabine 1 000 mg/m2 twice a day orally, d1~14. FOLFOX (2 weeks/course of treatment): oxaliplatin 85 mg/m2 intravenous d1, leucovorin 400 mg/m2 intravenous d1, fluorouracil (5-FU) 400 mg/m2 intravenous d1, followed by 2 400~3 600 mg/m2 civ for 46 h. SOX (3 weeks/course of treatment): oxaliplatin 130 mg/m2 intravenous d1, Tigio 40 mg/m2 twice a day oral d1~14.
2. Targeted therapy: trastuzumab combined with chemotherapy regimens (such as oxaliplatin/cisplatin + 5-FU/capecitabine) is the first-line treatment regimen for HER2-positive patients, ramucirumab (anti-VEGFR2 monoclonal antibody) monotherapy or combined with paclitaxel is recommended as the second-line treatment regimen, and apatinib mesylate (VEGFR-2 small molecule tyrosine kinase inhibitor) is recommended as the third-line or above third-line treatment regimen for advanced gastric cancer or esophagogastric junction adenocarcinoma.
3. Immunotherapy: Immune checkpoint inhibitors combined with chemotherapy have been approved as first-line treatment drugs for gastric cancer. Nivolumab and pembrolizumab are more commonly used to treat recurrent or metastatic adenocarcinoma of the stomach or esophagogastric junction with a high PD-L1 combined positive score (CPS). For patients with peritoneal metastases of gastric cancer with microsatellite instability-high (MSI-H) and mismatch repair deficiency (dMMR), pembrolizumab and nivolumab can be used for first-, second- or third-line therapy.
(2) Abdominal treatment
Recommendation 15: Commonly used abdominal treatment modalities mainly include HIPEC and NIPEC. (Quality of evidence: moderate; level of recommendation: strong recommendation, panel approval rate: 98.2%)
Due to the existence of the peritoneal-plasma barrier, higher concentrations of chemotherapy drugs can be perfused into the peritoneal cavity for the removal of tumor cells without causing severe systemic toxicity, but the passive penetration of intraperitoneal chemotherapy is only 1~3 mm aerosolized chemotherapy, PIPAC). HIPEC was first reported in 1980 to increase the depth of drug penetration by increasing the perfusate temperature. In a domestic multicenter retrospective study of 663 patients with gastric cancer with peritoneal metastases, the results showed that the median survival was prolonged in the HIPEC plus chemotherapy group compared with the chemotherapy alone group (15.9 months versus 10.8 months). NIPEC treatment implants chemotherapy pumps in the abdominal wall and infuses chemotherapy drugs at a fixed frequency, which has the advantages of less invasiveness, long duration of action, flexibility and convenience, and outpatient medication, but the incidence of adverse reactions associated with intraperitoneal chemotherapy pumps can reach 22.9%. In clinical practice, attention should be paid to key management and maintenance. PIPAC technology was first reported in 2012 to improve intraperitoneal drug distribution and penetration depth by means of compression. One of the advantages of PIPAC technology is that the concentration of perfused chemotherapy drugs is only 1/10 of that of HIPEC treatment, which further reduces drug toxicity, but more research is needed on PIPAC as a new technology in clinical practice, and this consensus does not recommend it for the time being.
Recommendation 16: Drugs commonly used in intraperitoneal therapy include paclitaxel, docetaxel, cisplatin, and oxaliplatin. (Quality of evidence: moderate; level of recommendation: strong recommendation, panel approval rate: 97.3%)
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Chinese Expert Consensus on the Diagnosis and Treatment of Peritoneal Metastasis of Gastric Cancer (2023 Edition)
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