Oncology Frontier: Peritoneal carcinomatosis related to gastric cancer is associated with a poor prognosis. Now， cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has been shown to improve the prognosis of tumors. What do you think of the role and status of HIPC in gastric cancer patients with peritoneal metastasis post cytoreductive surgery?

　　《肿瘤瞭望》：伴有腹膜转移的胃癌患者预后很差，减瘤术并术后进行腹膜内高温热灌注治疗（HIPEC）被证明可以改善肿瘤患者预后，您认为HIPEC在腹膜转移的胃癌患者接受减瘤术后的治疗中的作用和地位如何？

　　Dr da Costa: For the role of HIPEC in gastric cancer patients with peritoneal metastases， there is a Chinese trial with 68 patients that has demonstrated that when the patient has peritoneal carcinomatosis from gastric cancer， if the patient receives cytoreductive surgery with HIPEC， these patients will have a superior survival in comparison to cytoreductive surgery alone. The only thing I think is mandatory is that you have proper patient selection. Not every patient with peritoneal carcinomatosis from gastric cancer is a good candidate. We should also talk about what kinds of patients should be selected. First of all， these patients should receive systemic chemotherapy before surgery and the patients who have a good clinical laboratory or imaging response to chemotherapy should be good candidates. They should also not have too much disease; disease should be confined to the peritoneum and there should be no liver disease or at other sites. Also， a complete cytoreduction should be possible. Between HIPEC and early post-operative intraperitoneal chemotherapy， the strongest evidence supports HIPEC， so that would be the preferred choice. The adverse effects of treatment depend on the drugs. The most frequently used today are cisplatin and oxaliplatin. Cisplatin is associated with renal failure. Oxaliplatin is not so problematic post-operatively but intraoperatively it can induce hyperglycemia and hyponatremia. Time also depends on the chemotherapy used. Cisplatin is generally used over 60 minutes or 90 minutes. Oxaliplatin is 30 minutes， mainly due to that intraoperative toxicity.

　　Dr da Costa:对于那些腹膜发生转移的胃癌患者是否需要HIPEC的问题，有一个68例的中国研究展示当有腹膜转移的胃癌患者接受减瘤手术和HIPEC治疗后，他们的生存时间明显长于只接受减瘤手术的患者。我认为唯一需要强制规定的是选择哪些患者接受这样治疗。并不是每一个腹膜转移的胃癌患者都是合适的人选。我们应该讨论一下什么样的患者应该选择这样的治疗。首先，那些在术后接受过系统性化疗的患者，以及那些在实验室指标和影像学上表现对化疗反应非常好的患者都是适合HIPEC治疗的。同时他们不能有太多其他的疾病，这个疾病被定义为腹膜转移，而不应该有肝转移或者其他部位的转移。同时，一个完全的减瘤手术应该是要完成的。在HIPEC和术后早期的腹腔内化疗两者中，有更多的证据支持HIPEC，所以我们也应该优先选择HIPEC。这个治疗的不良反应主要是因为化疗药物。现在最常用的的药物有顺铂和奥沙利铂。顺铂和肾衰相关。奥沙利铂在术后或者术中化疗使用中问题较少。化疗的时间同样要依据用了什么样的化疗方案。顺铂经常是要用到60秒或者90秒以上。而奥沙利铂因为化疗毒性只能用到30秒。

　　Oncology Frontier:  You mentioned the Chinese study with 68 patients. Is that a large enough number of subjects for this kind of study?

　　《肿瘤瞭望》：您刚才提到中国的研究有68例患者，对此类研究而言，这样的样本数量足够吗？

　　Dr da Costa:  That number of patients can mean the study is underpowered. That would the consequence of smaller numbers. In this case， I think this study has some other issues with patient selection. Almost 40% of those patients had incomplete cytoreduction and a very high PCI (too much disease). I think patient selection could be an issue here. It is still the only study however， that shows there is benefit in using HIPEC compared to surgery alone. That data is not available for any other disease， just gastric cancer. There are potential issues with the study but it is still evidence that we wouldn’t otherwise have.

　　Dr da Costa: 这个研究的病例数不够有说服力，主要是样本量太小。在这个研究中，我认为在患者的选择上海存在着一些问题。大概40%的病人并没有接受一个完整地减瘤术而且还有很多的其他转移病灶。我认为患者的选择在这个研究中是有问题的。但是因为这是目前唯一的一个研究证实与单纯减瘤术相比，加上HIPEC后患者更加获益。同时这个数据只适用于胃癌，并不能推广到其他肿瘤。虽然这个研究有不少潜在的问题，但是它依旧是我们之前没有的数据证明。