HIPEC. Years of life instead of months for malignant tumors of the abdominal cavity

Chemotherapy is included in standard treatment regimens for stomach cancer. The expected result of the action of chemotherapy is the complete death of cancer cells or inhibition of their vital activity, preventing tumor growth and the appearance of metastases. Recently, the concept of chemotherapy has expanded due to the use of new types of drugs.

• Targeted therapy is essentially the use of chemicals that act selectively on cancer cells, with minimal impact on healthy ones. As a result, such treatment is tolerated much easier by the body and causes fewer consequences.
• Hormone therapy is used to treat hormone-dependent tumors.

Influence of gastric cancer stage on prognosis and choice of treatment

The successes of chemotherapy have not changed the main thing - it is impossible to cure cancer without surgery. The most favorable prognosis will be only for a very small malignant lesion - no higher than stage 1A, when cancer cells have not penetrated into the muscles of the stomach wall and have not reached the lymph nodes. With this type of cancer, nine out of ten patients can expect a long life without additional drug treatment.

If the cancer has spread beyond the stomach and invaded the surrounding tissue, resection of neighboring organs is performed. Conservative (drug) antitumor therapy improves the overall outcome, allowing eight out of ten patients with stage 2–3 and initially operable cancer to live for more than 3 years, and the majority will not have signs of the disease during these years.

In a very common process, surgery plus chemotherapy improves the prognosis, but only half of patients can hope to live long enough. The prognosis for stage 4 cancer with metastases leaves much to be desired.

Stages of the disease

Like most oncological neoplasms, stomach cancer is an insidious disease that does not make itself felt until stage 2 of the disease. Therefore, it is very important to undergo regular examinations in medical centers: this will allow you to detect cancer in the early stages and get rid of it without radical methods. The following stages of oncology are determined by the size and spread of the tumor.

Stage 0. The tumor does not manifest itself in any way; this is the moment of its inception. It can only be detected during examination using MRI and other modern techniques.

Stage 1. The tumor is located in the superficial layer of the mucous membrane, but has not yet begun to spread. This is the so-called “cancer in situ”, which is easier to treat than other forms of the disease. However, the symptoms practically do not manifest themselves, so the patient, as a rule, does not yet know about the occurrence of oncology.

Stage 2. The tumor begins to grow into the muscle layer of the stomach, and the first symptoms of the disease begin to appear, which can easily be confused with poisoning or indigestion.

Stage 3. The tumor has reached the outer lining of the stomach. Symptoms become more pronounced, but at this stage the cancer has not yet begun to affect nearby organs.

Stage 4. The tumor has grown into the outer shell and began to spread to other tissues. As a result, cancer affects the nearest lymph nodes, forms metastases in the organs of the reproductive system, and spreads throughout the body.

Up to stage 3, oncological tumors in the stomach can be effectively treated using modern techniques. However, the further the metastases spread, the less chance of a complete recovery. Therefore, at the first manifestations of the disease, you should immediately go for a medical examination.

Why is chemotherapy needed after surgery?

This type of antitumor treatment is called adjuvant; it is aimed at cancer cells circulating in the blood and lymph that can become a source of metastases or relapse.

Clinical studies have shown that taking the chemotherapy drug capecitabine for stages 2–3 gastric cancer within a year after surgery increased by 10% the number of patients who lived for more than 3 years. Six months of combination chemotherapy led to an increase in the group of those who lived more than 3 years without relapse and metastases by 15%.

Neoadjuvant chemotherapy

Neoadjuvant (preoperative) chemotherapy is usually prescribed for stages T2-4N1-3 stomach cancer. Treatment has the following goals:

• Downstage the disease and improve resectability of the tumor - simplify its surgical removal.
• Destroy micrometastases that may be present in the patient’s body, but are not detected during the examination.
• Determine sensitivity to chemotherapy drugs at the initial stages of treatment.
• Reduce the risk of cancer recurrence after surgery at the site of the primary tumor or as distant metastases.
• Increase patient survival.

Before surgery, three courses of chemotherapy are given. Combinations of drugs commonly used are CF (cisplatin + 5-fluorouracil), ECF (epirubicin + cisplatin + 5-fluorouracil), ECX (epirubicin + cisplatin + capecitabine) or EOX (epirubicin + oxaliplatin + capecitabine). Then, if the cancer is resectable (it can be removed surgically), surgery is performed. After surgery, three courses of chemotherapy are administered again.

In what cases is chemotherapy useful before and after surgery?

The use of chemotherapy in two blocks - before and after surgery or perioperatively is standard in European countries; Russian oncologists predominantly use postoperative drug treatment, which is due to the organizational characteristics of the state oncology service. For technically inoperable stomach cancer without metastases, 3 courses are carried out according to regimens of 2 or 3 drugs, then, if successful, surgery is performed and chemotherapy treatment continues. The total number of courses is 6.

In studies, this type of antitumor treatment led to an almost twofold increase in the number of patients surviving five years, including without signs of disease relapse.

Results and discussion

All patients of the main group completed the planned course of treatment in full and on time. At the stage of preoperative chemotherapy, adverse reactions were noted in 9 (31.0%) patients; emetogenic complications predominated (20.6%), mainly in the form of grade I-II nausea, which did not require a break in the NACT course and were well controlled by standard accompanying therapy. There were no serious hematological complications, 7 (24.1%) patients had grade I leukopenia, 3 (10.3%) had grade I anemia, the latter most likely was associated with manifestations of the underlying disease, and not with the administration of cytostatic therapy. In all cases, adverse reactions did not require interruption of chemotherapy courses and were treated with standard accompanying therapy. Thus, the courses of NACT according to the FOLFOX regimen were characterized by satisfactory tolerability and a low level of toxicity, which did not have a negative impact on the surgical component of the combined treatment of GC.

When analyzing the surgical stage of combined treatment in the main group, it was found that surgical interventions were performed as planned - 3 weeks after completion of NACT. In this case, the type of surgical treatment was determined based on the results of the initial examination conducted before chemotherapy; a reduction in the volume of intervention, even with significant or complete regression of the tumor after NACT, was not performed.

In the main group, resectability was 100%; in most cases, radical operations were performed - 93.1% (Table 1). In 1 (3.5%) patient after gastrectomy, histological examination of the surgical material revealed tumor cells along the proximal resection border - operation R1; in 1 (3.5%) patient, intraoperative revision revealed a previously undiagnosed metastatic focus in the right lobe of the liver , a subtotal gastrectomy was performed - operation R2. In the control group, all radical operations met the R0 criterion.

Table 1. Volume and nature of operations performed in the compared groups

The volume of operations performed in the compared groups was the same (see Table 1); gastrectomy was performed in more than half of the patients. In all cases, perigastric lymphadenectomy D2 was performed with mandatory circular dissection of the hepatoduodenal ligament; the number of removed lymph nodes in the compared groups was the same.

In the postoperative period, complications occurred in 9 patients in each group, which amounted to 31.0 and 27.3%, respectively ( p

>0.05).
In most cases, they manifested themselves as reactive pleurisy on the left, mainly after combined operations with resections of adjacent organs. In the control group, complications of a purulent-inflammatory nature were more often detected, which in 3 (9.1%) cases required relaparotomy and additional drainage of the abdominal cavity; subsequently, these phenomena were stopped. In the main group, no repeated operations were performed. In 24.2% of patients, on days 2–5 after surgery, an increase in blood amylase levels was noted, but this was not accompanied by clinical manifestations of postoperative pancreatitis and was relieved by the prescription of protease inhibitors and octreotide according to the method developed in the clinic [15]. In the early postoperative period, 2 patients died, one patient in each group, the mortality rate was 3.5 and 3.0%, respectively ( p
>0.05). The causes were non-surgical complications: in the main group, death was a consequence of acute transmural myocardial infarction, which developed on the 5th day after subtotal gastrectomy; in the control group there was a massive thromboembolism of the pulmonary artery that occurred on the 3rd day after gastrectomy. Thus, carrying out 2 courses of NACT according to the FOLFOX regimen in patients with gastric cancer had no effect on the course of the perioperative period; the frequency, nature and severity of postoperative complications are determined by other factors, primarily the volume of surgical intervention performed and the initial somatic condition of the patient.

As indicated, the stratification of patients according to the stages of the tumor process was carried out taking into account the data of histological examination of the surgical material. Distribution by stages (TNM classification, 7th edition, 2009) [16] is presented in table. 2. It is noteworthy that in patients of the main group the tumor process is less widespread than in the control group, despite the fact that at the stage of preoperative diagnosis the primary tumor in all cases was regarded as locally advanced R.Zh. In our opinion, this is due to the “downstaging” phenomenon during preoperative chemotherapy; downstaging to pT0—2N0M0 was recorded in 10 (34.5%) cases. Indeed, when assessing the immediate effectiveness of NACT and the severity of therapeutic pathomorphosis in the main group, it was found that complete, morphologically confirmed regression of the tumor (medicinal pathomorphosis of IV degree) was registered in 3 (10.3%) cases, partial regression - in 18 (62.1 %), stabilization of the process - in 7 (24.1%), progression of the disease (metastatic liver damage identified during intraoperative revision) - in 1 (3.4%) observation.

Table 2. Distribution by stage in the compared groups, taking into account the morphological examination of the surgical material

The period of follow-up after treatment was 12-42 months, most patients were observed for more than 24 months. During monitoring in the main group, progression of the tumor process was recorded in 5 patients 6–15 months after surgery, which manifested itself in the form of hematogenous metastases or peritoneal dissemination. Locoregional relapse occurred in 1 patient who underwent R1 surgery during the first year after treatment. Unfavorable prognosis factors were metastatic liver disease, surgery R2 (1 patient), surgery R1 (1 patient), tumor spread to the esophagus (2 patients), and prevalence of the tumor process T4a-bN2-3 (4 patients). 4 patients had a combination of several unfavorable signs. In the control group, there were no local relapses during long-term follow-up, but distant metastases developed in 6 patients in the 1st year of observation, and in 3 patients in the 2nd year. Thus, 1-year survival rate in the main group was 85.7%, in the control group - 81.3% ( p

>0.05).
Significant differences in long-term results in the compared groups of patients appear when analyzing 2-year survival rates - 82.1 and 68.8%, respectively ( p
<0.05).

We present a clinical case of locally advanced cancer with complete morphological regression of the tumor focus.

Patient P.

, born in 1958, entered the thoracoabdominal department of the Federal State Budgetary Institution “Research Institute of Oncology” of the Siberian Branch of the Russian Academy of Medical Sciences on August 20, 2010. A comprehensive examination diagnosed stage III GC (T3N+M0). During endoscopy (08/30/10), an ulcerative defect with a diameter of up to 0.4 cm is visualized in the antrum of the stomach along the anterior wall, with radially spreading infiltration extending from the lower third of the body of the stomach to the pylorus; the tissue is fragmented during biopsy and bleeds moderately. Conclusion: tumor of the antrum of the stomach, infiltrative-ulcerative form of growth. Endoscopic ultrasonography (09/01/10) revealed a tumor of the gastric outlet with possible infiltration of the serous membrane and adjacent tissues. The results of the endoscopic examination were confirmed by CT scanning of the abdominal organs; in addition, enlarged lymph nodes were detected in the lesser omentum, one of them with a diameter of up to 4 cm (Fig. 1). Histological examination of biopsy material (08/11/10): poorly differentiated adenocarcinoma (Fig. 2).

Rice. 1. Computer tomograms of the abdominal organs before the start of combined treatment. On the left scan, the arrow indicates the extent of the primary tumor; on the right scan, an enlarged perigastric lymph node.

Rice.
2. Microphoto. Poorly differentiated gastric adenocarcinoma. Hematoxylin and eosin staining, ×400. Considering the prevalence of the tumor process, the patient received 2 courses of preoperative chemotherapy according to the FOLFOX6 regimen. The treatment was tolerated satisfactorily, no adverse reactions were observed. During the control examination before surgery, a decrease in tumor size from 6 to 3.1 cm, a decrease in the size of the lymph node from 4 to 2.3 cm, as well as the disappearance of smaller perigastric nodes was noted (Fig. 3).

Rice. 3. Computed tomograms of the abdominal organs 2 weeks after completion of the 2nd course of neoadjuvant chemotherapy according to the FOLFOX regimen. There is a decrease in the size of the primary tumor and perigastric lymph nodes.

On 10/06/10 the patient underwent subtotal distal gastrectomy and D2 lymphadenectomy. On a macroscopic specimen in the antrum of the stomach, along the lesser curvature, against the background of an atrophic mucous membrane, a residual ulcerative defect with a diameter of less than 1 cm was determined; no macroscopically changed perigastric lymph nodes were detected (Fig. 4). The postoperative period proceeded without complications, healing by primary intention. The patient was discharged in satisfactory condition on the 14th day after surgery.

Rice. 4. Macropreparation. Against the background of the atrophic mucosa of the antrum and the lower third of the body of the stomach, superficial ulceration with a diameter of less than 1 cm is determined.

During a routine histological examination of the surgical material (10/19/10), a chronic gastric ulcer, inflammatory infiltration spreads to the entire wall of the antrum of the stomach, where fibrosis and lymphoplasmacytic infiltration are pronounced. No tumor cells were found. Drug pathomorphosis of IV degree. In the lymph nodes there is sinus histiocytosis.

During a follow-up examination in March 2014, no signs of progression of the tumor process were revealed.

What are cycles?

Chemotherapy drugs attack not only tumor cells, but also healthy cells in which division processes are actively occurring. After the body has received the next dose of medicine, it needs to “catch its breath” and recover. Therefore, chemotherapy is always carried out in cycles: after the next administration of drugs there is a break. For stomach cancer, chemotherapy drugs are usually administered intravenously, sometimes taken in tablet form. Cycles can last 14, 21 or 28 days.

How to restore the stomach after chemotherapy?

Despite the high effectiveness of chemotherapy, after its course, special treatment is required to restore the functioning of organs damaged during therapeutic measures. The main tasks in this case are to normalize the functioning of the body’s internal systems, strengthen the human immune system and rid it of intoxication, that is, eliminate disorders caused by taking potent drugs.

Each specific patient needs an individual program to restore the body, which includes not only diet, but also physical therapy, swimming, lymphatic drainage, aroma and juice therapy, and cleansing the body with herbal infusions.

Restoring the stomach after chemotherapy involves going through certain rehabilitation stages:

• elimination of general severe intoxication. Good results are achieved by strengthening the drinking regime with decoctions of berries and medicinal herbs, as well as regular intake of diuretic herbal compounds;
• removal of toxic substances from the gastrointestinal tract. For this, mucus-secreting plants are used, for example flax seed, marshmallow or angelica, Polyphepan and Activated carbon;
• correction of dysbacteriosis. To do this, use a composition prepared on the basis of a combination of herbs such as Icelandic cetraria, creeping thyme and wild rosemary;
• restoration of microflora in the digestive organs is carried out by live strains of beneficial bacteria, which are found in large quantities in certain lactic acid products.

A recovery program for eliminating malignant neoplasms from the digestive organ is required even when chemotherapy for stomach cancer is selected correctly by a specialist and includes only modern, highly effective drugs that prevent the occurrence of most possible side effects.

Patients are often interested in how chemotherapy for stomach cancer works? Knowing the answer to this question allows a person with cancer to be prepared for all the nuances of this treatment method. According to leading experts, the medications used for it can not only entail a large number of negative consequences, but also lead to significant deterioration in the general condition of the patient.

That is why attending physicians carefully weigh all the pros and cons before prescribing a specific course. Also, during such treatment, oncologists conduct regular diagnostic examinations to monitor the effectiveness. They make it possible to make the necessary adjustments to the therapeutic course.

Chemotherapy drugs

More than a dozen chemotherapy drugs are effective for malignant tumors of the stomach and intestines, almost all of them are used in different combinations. Combinations of three drugs are preferable in terms of results, but their tolerability is somewhat worse, so such regimens are prescribed to patients without chronic diseases with good general health.

In elderly patients with concomitant diseases and poor initial health, you can initially use one drug and, when the condition improves, switch to a two- or three-component regimen.

Doctors at the European Clinic use chemotherapy drugs recommended by the American National Comprehensive Cancer Network (abbreviated as NCCN, USA).

The most commonly used combination of fluoropyrimidine derivatives (fluorouracil, capecitabine) with platinum drugs (cisplatin, oxaliplatin) and the antitumor antibiotic epirubicin or docetaxel. Two-component regimens include fluoropyrimidines with irinotecan or platinum drugs.

Equal effectiveness of all regimens was noted; they differ only in complications and are completely interchangeable, that is, if one regimen is intolerable, you can continue treatment with another.

Long-term (over 24 or 48 hours) administration of fluorouracil through a special infusion system gives better results than rapid intravenous administration (stream) together with the “amplifier” leucovorin. If a daily infusion of fluorouracil is not possible, then it is better to take capecitabine tablets for 2 weeks.

The main condition for the success of chemotherapy is compliance with dosages and intervals between courses.

What happens after HIPEC?

Treatment results vary depending on the type of malignant tumor, the number and size of lesions in the abdominal cavity, and other factors. For example, pseudomyxoma has a better prognosis than colorectal cancer and malignant mesothelioma.

HIPEC could potentially destroy all tumor cells and completely cure the patient. However, even if a cure cannot be achieved, life expectancy increases significantly: it is years instead of months.

Previously, in order to undergo HIPEC, patients from Russia were forced to go to foreign clinics. Now this technique is available in Moscow. At the Medicine 24/7 clinic, the procedure is performed by experienced oncologist surgeons and chemotherapists who have been trained in leading oncology centers abroad. Contact us and get advice from our specialist doctor.

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Chemotherapy for gastric cancer with metastases

At this stage, cancer is not subject to surgical treatment; an exception is possible only if the stomach is technically removed and metastases to the ovaries without cancerous lesions of any other organs or tissues. For cancer complicated by bleeding, minimal palliative surgery is performed. A patient with a metastatic stage receives chemotherapy according to any standard regimen that he can tolerate.

The use of monotherapy—one drug—gives the worst results. Two-drug regimens with less toxicity are preferred, but in clinical studies only three-drug combinations have demonstrated an increase in survival.

If the patient feels well and does not have concomitant chronic diseases, then it is better to fight for life with three chemotherapy drugs at once. You can start chemotherapy with one drug, and when your condition improves, switch to more effective combinations.

If the effect is good, no more than 6–8 courses are carried out, then the patient is observed. If cancer growth resumes after 3 months, a second line of therapy can be started with the same combination that was used initially. If the process progresses in the next 3 months after completing chemotherapy courses, a complete change in the regimen is recommended; it does not include previously used drugs - most likely, the tumor has become resistant to them.

Chemotherapy after gastric removal

Sometimes patients with cancer of the main digestive organ cannot avoid its removal. Surgery for stomach cancer, which involves partial or complete resection, must also be accompanied by chemotherapy. This therapy plays a preventive role. The course of chemotherapy prescribed after removal of the digestive organ with the malignant tumor present in it has a direct target orientation. It consists of destroying the remaining abnormal cells circulating in the bloodstream that can cause a relapse or trigger the development of metastases.

After resection of the digestive organ, chemotherapy should begin no earlier than 1.5-2 months later. The therapeutic regimen is determined directly by the specialist, taking into account the general condition of the patient and all the nuances of the pathological condition identified during postoperative diagnosis.

The following scheme is usually used:

• chemotherapy in tablets. This part of the antitumor course prescribed after gastrectomy consists of taking Capecitabine for two weeks;
• intravenous chemistry. This involves a single intravenous administration of Oxaliplatin, a drug that is a platinum derivative.

This course, starting after normalization of blood counts, is designed for six months, and its scheme is coded CAPOX, according to the trade names of the drugs used in it, Capecitabine and Xeloda. During this time, 6 cycles of therapy are carried out with mandatory three-week breaks.

Targeted drugs

In addition to classical chemotherapy, targeted drugs are used for malignant tumors of the stomach. They act specifically on specific target molecules that play an important role in the survival and growth of a malignant tumor.

Ramucirumab (Cyramza) blocks the vascular endothelial growth factor (VEGF) receptor on the surface of the cells lining the inside of blood vessels. Tumor cells produce VEGF in order to stimulate the growth of new blood vessels, because they need a lot of oxygen and nutrients.

Ramucirumab is administered as a solution intravenously through a drip over 1 hour, every two weeks on the first day of chemotherapy.

Trastuzumab blocks the membrane protein HER2, which is located on the surface of cells in the gastric mucosa. If there is a lot of HER2, it activates the proliferation of tumor cells. Trastuzumab is administered intravenously in parallel with chemotherapy.

How is the procedure performed?

The technology for performing HIPEC may vary in different clinics. They use different chemotherapy drugs and their combinations, different temperatures, and volumes of solution for washing the abdominal cavity. But the general points are the same everywhere; treatment consists of two stages.

Stage I. Cytoreductive surgery

HIPEC is an adjunct to surgery and cannot be effective without prior surgery. First, the surgeon must remove all large, visible tumor lesions. To do this, all affected organs and areas of the peritoneum lining the walls of the abdominal cavity are completely or partially removed. Then the organs on which the intervention was performed are restored, for example, anastomoses are applied - the ends of the intestine are sewn together if a section of it was removed.

This is a rather complex surgical procedure. The surgeon must have sufficient experience and professionalism to correctly assess the situation and ensure maximum cytoreduction (remove all lesions). And the patient must be in good enough health to undergo the operation.

Stage II. Hyperthermic intraperitoneal chemotherapy

After the surgery is completed, catheters are placed in specific locations in the abdomen and connected to a perfusion system that delivers a heated chemotherapy solution. In addition, sensors are placed in the patient's abdomen to monitor temperature.

Tumor cells die at a temperature of 40° C, and normal tissues remain viable up to 44° C.

In order for HIPEC to have the desired effect, the abdominal cavity must be rinsed for 1–1.5 hours. Along with surgery, treatment can last from 6 to 18 hours.

After the required time has passed, the drug solution is removed from the abdominal cavity and washed with saline. Catheters and temperature sensors are removed and sutures are applied.

In case of recurrence of stomach cancer

As with primary cancer, surgical removal is considered first. If surgical intervention is technically impossible, then drug therapy is used with or without radiation. The principles of chemotherapy do not change.

Removing part or all of the stomach causes irreparable damage to the body. In addition, a long course of chemotherapy leads to all sorts of complications, and this radically affects the patient’s quality of life. To minimize the toxicity of chemotherapy drugs, the doctor must select them correctly, prescribe optimal doses and frequency of administration.

Find out the exact cost of treatment

In the European clinic, to reduce complications, preliminary drug preparation is carried out, and throughout the entire period of treatment the patient receives a special diet - nutritional support that promotes rapid recovery. Each of our patients receives an individual program of chemotherapy and rehabilitation support, and this helps to significantly improve treatment results.

We know how to help, even with advanced metastatic stomach cancer. If the patient cannot be cured, at least you can try to prolong his life as much as possible and relieve him of painful symptoms, slow down the growth of the tumor for a while, and reduce its size. Make an appointment with an oncologist at the European Clinic.

Chemotherapy for resistant disseminated gastric cancer: a literature review of treatment options

Gastric cancer ranks second in the structure of morbidity and mortality among malignant neoplasms in the Russian Federation [1]. In the world, stomach cancer ranks fourth in the structure of incidence of malignant neoplasms, and in the structure of mortality - second in men and fourth in women. The incidence ratio between men and women is 1.5:1 [2]. About 70% of new cases of gastric cancer occur in developed countries [3]. However, over the past 50 years, there has been a steady decrease (up to 60%) in the incidence of gastric cancer [4]. Many countries have reported a decrease in mortality compared to morbidity [5]. In contrast to the current trend, in some populations an increase in the number of patients with gastric cardia disease has been detected [6]. Countries with high incidence have been shown to have longer survival than countries with low incidence [7, 8]. This may be explained by the success of screening programs, for example, in a country such as Japan. In Japan, gastric cancer is diagnosed at stages I, II and III in 50.5%, 26.9% and 14.0% of patients, respectively, and their 5-year population survival rates are 95.2%, 39.8% and 2. 9% respectively [9].

In most cases, gastric cancer is diagnosed at late stages [10]. In more than two thirds of patients, the disease is detected only at stage IV, when the tumor is no longer resectable. In Russia in 2006, only 23.3% of patients had the disease at stages I–II; the 5-year population survival rate did not exceed 13% [1]. The EUROCARE-4 study showed that the 5-year survival rate of patients with gastric cancer in Europe was only 24.1% [11]. Despite R0 resections in patients with local and locally advanced disease, the relapse rate is high (up to 70%), and the 5-year survival rate does not exceed 30% [12].

Until recently, there were differing opinions about the improvement of survival in metastatic gastric cancer (mGC) with chemotherapy. A meta-analysis by AD Wagner et al. [13], answered this question and demonstrated a significant increase in survival when comparing chemotherapy with supportive care, despite a small sample size. Three randomized trials [14–16] involving a total of 184 patients showed that chemotherapy, when compared with supportive treatment, increases the life expectancy of patients with gastric cancer (9–11 months and 3–4 months, respectively, HR = 0.39). Another analysis comparing polychemotherapy with monochemotherapy demonstrated significant differences in favor of polychemotherapy (HR = 0.83, p = 0.001).

First line chemotherapy for metastatic gastric cancer

In table Figure 1 presents key phase II–III studies conducted since the 1990s. to 2008 and dedicated to first-line chemotherapy for mGC. In the 1990s. in a number of European countries, the FAMTX regimen (5-fluorouracil + doxorubicin + methotrexate) was the standard [17] until it showed an advantage over the FP (5-fluorouracil + cisplatin) and ELF (etoposide + leucovorin + 5- fluorouracil) [18]. Another randomized trial conducted in England showed a survival advantage of the ECF regimen (epirubicin + cisplatin + 5-fluorouracil) compared with FAMTX [19]. The results of these studies indicate a short survival time for patients, with a median of 6 to 8 months and an objective response rate of 20% to 40%. The survival benefit was limited to patients with good ECOG status. High toxicity of first-line chemotherapy regimens (especially cisplatin-containing regimens) was also noted. On the one hand, there was no survival benefit with the addition of epirubicin to the FP regimen, and on the other hand, there was no phase III trial that could directly compare the two regimens. Since then, ECF and FP regimens have become the standard first-line chemotherapy for mGC in many European countries. When comparing the results of classical chemotherapy regimens, the median survival remained at 8 to 10 months, and there was no advantage of one regimen over another. Due to the limited effectiveness of classical regimens, the role of docetaxel, irinotecan, oxaliplatin and oral fluoropyrimidines (capecitabine, S-1) in modern regimens has begun to be studied.

In the randomized trial V-325, E. Van Cutsem et al. [20], which included 445 patients, compared the DCF regimen (docetaxel 75 mg/m2 on day 1, cisplatin 75 mg/m2 on day 1, and 5-fluorouracil 750 mg/m2 per day, infusion for 5 days, cycle repeated every 3 weeks) and CF (cisplatin 100 mg/m2 day 1 and 5-fluorouracil 1000 mg/m2 per day, infusion for 5 days, cycle repeated every 3 weeks). The study demonstrated superiority of the DCF regimen compared to CF in terms of immediate treatment effectiveness (37% and 25% objective effects, respectively). Median life expectancy (MLL) was 9.2 and 8.6 months, 2-year survival rate was 18.4% and 8.8%, respectively (p = 0.02). However, a higher myelotoxicity of the DCF regimen was noted (febrile neutropenia - in 29% and 12% of cases, neutropenia grades III and IV - in 82% and 57% of cases, diarrhea in 19% and 8% of cases, respectively). Despite high toxicity, the addition of docetaxel to the CF regimen improved survival and quality of life [21, 22]. The authors concluded that the DCF regimen can currently be considered as a standard regimen in the treatment of mGC.

In the REAL-2 study, D. Cunningham et al. [31] randomized 1002 patients to treatment with one of a three-component regimen: 1) epirubicin + cisplatin + 5-fluorouracil (ECF) or capecitabine (ECX), 2) epirubicin + oxaliplatin + 5-fluorouracil (EOF) or capecitabine (EOX). Median life expectancy and 1-year survival when using ECF, ECX, EOF, EOX regimens were 9.9, 9.9, 9.3 and 11.2 months and 37.7%, 40.8%, 40.4% and 46.8% respectively. There were no significant differences in median time to progression or objective response rates. The toxicity of 5-fluorouracil and capecitabine was comparable. Compared with cisplatin, oxaliplatin was associated with a lower incidence of grade 3–4 neutropenia, renal toxicity, and thromboembolism, but a nonsignificantly higher incidence of grade 3–4 diarrhea and neuropathy. In general, EOX can serve as an alternative to the DCF mode.

The Japanese JCOG9912 [28] and SPIRITS [30] studies demonstrated high LFS (10 to 13 months) in all groups of patients who received regimens with infusion 5-fluorouracil, oral S1, irinotecan and cisplatin, cisplatin and S1. However, these results are determined not only by the effect of first-line chemotherapy. These patients also received second-line chemotherapy. The median time to progression with first-line chemotherapy in patients receiving the cisplatin + S-1 regimen was only 6 months, with the remaining 7 months of survival achieved through second-line chemotherapy. Also, such a high LRM can be explained by the nature of the study. Japanese studies allowed the inclusion of patients with measurable and non-measurable manifestations of the disease, while Western studies were limited to the inclusion of patients with measurable manifestations only. For example, in Japanese studies, more than 70% of patients received second-line chemotherapy, although only 32% of patients in the DCF group (study V325) received further chemotherapy [32].

Thanks to new combinations over the past 20 years, the lifespan of patients receiving first-line chemotherapy has increased from 6 to 10–11 months. However, despite the emergence of new effective regimens, MPV remains less than a year with short objective responses [33]. The key to improving overall survival is the use of effective chemotherapy in the future, with progression after the first line of treatment. However, in daily practice, second-line chemotherapy is not given to all patients. When progression occurs after first line, only 20–30% of patients receive further chemotherapy [20, 34]. This is due to the fact that when progressing after first-line therapy, most patients have a severe clinical picture, such as ECOG status ≥ 2, dysphagia, increasing ascites, pain, weight loss ≥ 10%. Carrying out chemotherapy for such patients results in serious complications due to both the toxicity of the antitumor drugs themselves and the peculiarities of the course of the disease. In particular, with gastric cancer, weight loss, dysphagia due to stenosis or obstruction, and bleeding from an unremoved primary tumor are noted. In such patients, chemotherapy poses a threat to life and is often complicated by the development of deep, often febrile, neutropenia, sepsis, stomatitis, enterocolitis, accompanied by severe diarrhea [35]. Treatment of difficult-to-tolerate chemotherapy is not always possible, and initiation of second-line chemotherapy is a matter of debate.

Second line chemotherapy for metastatic gastric cancer

Currently, the results of numerous randomized phase II studies are known, which assessed the effect of platinum derivatives, taxanes and irinotecan alone or in combination with other drugs (Table 2) in the second line of chemotherapy.

In 1985, a phase II study was conducted by AJ Lacave et al. [36] to study the role of cisplatin (100 mg/m2, every 3 weeks) in the second line of therapy in 31 patients. In the first line of treatment, 8 (50%) patients received the FAM regimen (5-fluorouracil + doxorubicin + mitomycin) and 6 (39%) received the FA regimen (5-fluorouracil + doxorubicin). As a result, an objective response was achieved in 3 (19.4%) patients, and the LFS was 3.5 months. In 1991, A. Ohtsu et al. [37] studied the effectiveness of the regimen of cisplatin (20 mg/m2, days 1–5, every 4 weeks) + 5-fluorouracil (800 mg/m2, days 1–5, every 4 weeks) in 20 patients.

In the first line, 10 (50%) patients received the EAP regimen. Disease control was achieved in 17 (85%) patients, MTP was 3.0 months for all patients and 8.0 months for patients who responded to treatment. Hematological toxicity of grade 3-4 was recorded in 45% of cases, stomatitis of grade 3-4 - in 40% of patients.

U. Vanhoeffer et al. [38] treated 17 patients with 5-fluorouracil (2600 mg/m2 24-hour infusion) and leucovorin (500 mg/m2) weekly for 6 weeks with a one-week break. In the first line, 14 (82%) patients received 5-fluorouracil in monotherapy. Disease control was achieved in 10 (59%) patients, including 3 (18%) patients achieved partial regression, and 7 (41%) patients achieved disease stabilization. LFS was 7.0 months in patients who responded to treatment. Toxicity in this group of patients was high: grade 2-3 diarrhea was observed in 18% of patients, grade 4 diarrhea in 6% of patients, grade 1-2 hand-foot syndrome in 24% of patients.

KE Shmid et al. [39] showed the effectiveness of raltitrexide and oxaliplatin in the second line of chemotherapy in 21 patients who had previously been treated with docetaxel and cisplatin (12 patients - 57%). All patients progressed within 6 months from the start of first line chemotherapy. Partial regression was noted in only one case, and disease stabilization was observed in 6 (29%) patients. Median time to progression (TTP) and MTP were 2.0 and 4.0 months, respectively. Grade 3–4 neutropenia and grade 3 diarrhea were observed in 15% and 5%, respectively.

F. Graziano et al. [40] and JL Lee et al. [41] studied the efficacy and safety of docetaxel alone as second-line chemotherapy. In a study by F. Graziano et al. 21 patients who showed disease progression after CF or PELF regimens were included. The following second-line chemotherapy regimen was used: docetaxel (36 mg/m2) weekly for 6 weeks followed by a 2-week break. Disease control was achieved in 9 (42.8%) patients, LFS was 3.5 months. Hematological toxicity of the 3rd degree was observed in 14.3%, asthenia of the 2nd degree - in 90%. A study by JL Lee et al. 49 patients were included who received the CF regimen in the first line of chemotherapy. The patient was treated with docetaxel (75 mg/m2) every 3 weeks. Disease control was achieved in 29 (59.2%) patients, LFS was 8.3 months. Neutropenia of 3-4 degrees was noted in 18.4% of cases, diarrhea of ​​3-4 degrees - in 10.2% of cases, peripheral neuropathy of the 2nd degree - in 8.2% of cases.

In a study by C. Barone et al. [44], which assessed the effectiveness and toxicity of second-line chemotherapy, included 38 patients with disease progression after ECF or CF regimens. As part of the study, patients were treated with docetaxel (75 mg/m2, day 1) and oxaliplatin (80 mg/m2, day 2) every 3 weeks. In 20 (52.6%) patients, the primary tumor was removed. Objective response and stabilization were achieved in 4 (10.5%) and 18 (47.3%) patients, and MEP and LFS were 4.0 and 8.1 months, respectively. Neutropenia of 3–4 degrees was noted in 26.3% of cases, peripheral neuropathy of 1–2 degrees — in 42.1% of cases. Thirteen (34.2%) patients subsequently received third-line irinotecan-containing chemotherapy. LFS were 16.3 and 6.0 months in patients who did and did not receive third line treatment, respectively. This study showed significant benefit from continuing chemotherapy. Interesting results were also observed when docetaxel was combined with epirubicin, capecitabine and cisplatin [42, 43, 45–47]. Combinations with docetaxel showed only a small increase in objective responses compared with docetaxel alone. Long-term treatment results were similar: MEP was 2–5, and MPV was from 5 to 8 months with more severe treatment tolerance.

Similar results were obtained when using paclitaxel alone or in combinations [48–54]. Weekly paclitaxel (60–80 mg/m2) was associated with less toxicity (16–32% grade 3–4 neutropenia) with similar objective effects (8–27%) compared with the standard 3-week regimen in a series of Japanese studies [49, 50 ]. Paclitaxel in combination with cisplatin showed a high incidence of grade 3–4 neutropenia (up to 34%) and grade 2–3 peripheral neuropathy (up to 38%) [53, 54].

Combinations of irinotecan with cisplatin and fluoropyrimidines are highly effective (27–52%) in second-line chemotherapy. JH Chun et al. [55] studied the efficacy and toxicity of irinotecan alone (125 mg/m2 weekly for 4 weeks followed by a break of 2 weeks) in 37 patients. Partial regression was achieved in 7 (20%) patients, and disease stabilization was achieved in 8 (22.8%). In more than 15 (40%) patients, the irinotecan dose was reduced due to high toxicity (grade 3 diarrhea - 8.5%; grade 3-4 neutropenia - 29.8%; infections - 5.4%; nausea/vomiting - 9.6%). With this regimen, the MEP and MPV were 2.6 and 5.2 months, respectively.

In a study by S. Shimada et al. [56] in 21 patients showed the high effectiveness of the combination of irinotecan (60 mg/m2, day 1) with cisplatin (6 mg/m2, day 1) weekly for 3 weeks, followed by irinotecan every 2 weeks. All patients received combinations with S-1 (tegafur + gimeracil (5-chloro-2,4 dihydropyridine) + oteracil (potassium oxonate (Oxo)) as first line. An objective response rate of 52% was achieved (including 9.5 % complete responses and 42.5% partial responses), with a high MTP - 7.9 months and LFS - 9.0 months. At the same time, no grade 3-4 toxicity was noted. This regimen improved the quality of life of patients during second chemotherapy lines.

In other studies [57–59], combinations of irinotecan with cisplatin demonstrated 15–28% objective response rates with a median survival of 5 to 9 months. In a study by JH Baek et al. [57] 31 patients were treated with irinotecan (70 mg/m2, day 1.15) and cisplatin (30 mg/m2, day 1.15) every 3 weeks to evaluate the effectiveness and safety of this regimen. An objective response rate of 15.6% was observed, with MTP and LFS of 3.8 and 6.1 months, respectively. Grade 3–4 neutropenia was reported in 18.8%, grade 3 anorexia in 12.5% ​​of cases, and grade 3 diarrhea in 6.2% of cases.

In a retrospective Japanese study, SH Ueda et al. [58] studied the effectiveness and safety of combinations of irinotecan (70 mg/m2, day 1.15) with cisplatin (80 mg/m2, day 15) every 4 weeks in 32 patients. A 28% objective response rate was obtained with MEP and MPV of 3.5 and 9.4 months, respectively. In this study, high toxicity was noted with grade 3 neutropenia in 69%, febrile neutropenia in 9%, and grade 3 diarrhea in 3% of cases.

The FOLFIRI regimen has shown moderate activity in second-line chemotherapy for mGC [60, 61]. In a Korean study, ST Kim et al. [60] studied the antitumor efficacy and toxicity of the FOLFIRI regimen (irinotecan 150 mg/m2, day 1; leucovorin 100 mg/m2, day 1; 5-fluorouracil 2000 mg/m2, day 1, 48-hour infusion, every 2 weeks). In the first line, all patients received combinations of taxanes with cisplatin. Of the 57 patients assessed, an objective response was achieved in 12 (21%), stable disease in 14 (25%) patients, with MVP and LFS of 2.5 and 7.6 months, respectively. Grade 3–4 neutropenia was reported in 11%, grade 3–4 thrombocytopenia in 3%, and grade 3–4 diarrhea in 3% of cases. In another study, S. Assersohn et al. [59] studied the effectiveness of the FOLFIRI regimen (irinotecan 180 mg/m2, day 1; leucovorin 125 mg/m2, day 1; 5-fluorouracil 1200 mg/m2, day 1, 48-hour infusion, every 2 weeks) in 38 patients with primary refractory or platinum-resistant tumor process. There were 29% objective responses, 34% stabilization of the disease with MVP and LRM of 3.7 and 6.4 months, respectively. There was an improvement in the quality of life of patients with relief of dysphagia in 30 (78%), pain in 21 (54.5%), anorexia in 25 (66.6%) and vomiting in 38 (100%) patients. Grade 3–4 neutropenia was noted in 10 (26.4%) patients, febrile neutropenia in 2 (5.2%) and infections in 6 (15.8%) patients.

The irinotecan + Mitomycin C regimen also has moderate effectiveness in the treatment of mGC in the second line of chemotherapy. In an Italian study by F. Giuliani et al. [62] studied the effectiveness of a regimen of irinotecan (150 mg/m2, day 1.8) and mitomycin (8 mg/m2, day 1), every 4 weeks in 38 patients. There was a 32% objective response rate with MEP and MFS of 4.0 and 8.0 months, respectively. This regimen was well tolerated with grade 3–4 neutropenia in 8 (21%) and grade 3–4 anemia in 2 (5%) patients.

A. Ono et al. [64] assessed the effectiveness of S-1 in second-line chemotherapy in 21 patients who showed disease progression after treatment with irinotecan and cisplatin/5-fluorouracil. The drug S-1 was prescribed in a dosage of 40 to 60 mg (depending on body surface area) 2 times a day, for 4 weeks of a 6-week cycle. In 10 (47.6%) patients, stabilization of the disease was achieved with MVP and MVP of 3.0 and 9.0 months, respectively. In this study, high LRM was achieved due to third-line chemotherapy in 16 (76%) patients. Neutropenia grade 3–4 was noted in 9.5% of cases, grade 4 anemia in 9.5%, and grade 3–4 diarrhea in 9.5%. The authors made the following conclusion: the drug S-1 in monotherapy is not effective in the second line of chemotherapy for mGC.

Similar results were obtained when Mitomycin C was prescribed alone [63].

Thus, table. Table 2 summarizes published phase II trials on the effectiveness of second-line chemotherapy in mGC. Despite the use of different combinations, objective responses do not exceed 20–25% and the median survival time is 5–6 months (from the start of second line chemotherapy). This may be due to the heterogeneity in the design of each phase II study conducted. The results obtained from these studies should be assessed with caution due to the high likelihood of selection bias. Interpretation of the role of second-line chemotherapy in the treatment of gastric cancer based on the results of the above-mentioned studies is extremely difficult. This is due to the wide variety of chemotherapy regimens used and patient selection criteria and assessment of prognostic and predictive factors. In addition, these studies provided insufficient data on the tolerability of second-line chemotherapy and the quality of life of patients.

At the 2009 Congress of the American Society of Clinical Oncology (ASCO) [67], the results of a randomized phase III trial were reported for the first time, which compared the effectiveness of second-line chemotherapy (irinotecan monotherapy) and maintenance therapy in 40 patients ( The study was stopped early due to slow patient enrollment). Second-line chemotherapy was shown to significantly improve survival compared with maintenance therapy (4.1 vs. 2.4 months, HR = 2.85, p = 0.0027). This study is the first evidence that second-line chemotherapy improves survival in patients with gastric cancer.

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S. A. Tyulyandin, Doctor of Medical Sciences, Professor M. N. Narimanov1, Candidate of Medical Sciences V. T. Zarkua

GU RONC im. N. N. Blokhin RAMS, Moscow

1 Contact information

Advantages of chemotherapy at the European Clinic

• We undertake the treatment of stomach cancer at stages III–IV. We often receive patients who were considered hopeless in other clinics and sent home to “live out their lives.”
• Doctors at the European Clinic work only with original chemotherapy drugs from Europe and the USA.
• We follow American NCCN treatment protocols.
• We provide chemotherapy courses in combination with other modern cancer treatment methods. Maintenance therapy helps to endure the administration of chemotherapy drugs as comfortably as possible and minimize side effects.

Get a treatment program

Side effects

In some cases, chemotherapy is the only way to treat cancer. But more often it is used as an additional treatment. The active substances of the drugs used significantly reduce immunity and cause the development of a number of side effects.

Patients experience hair loss, decreased appetite up to its loss, and the development of stomatitis. Most patients complain of nausea, which may be accompanied by vomiting. But the unpleasant symptom is eliminated with the help of special medications.

Among the side effects after chemotherapy, the development of osteoporosis, diseases of the cardiovascular system, and leukemia is also observed.

Prices for chemotherapy courses at the European Clinic

• Consultation with a chemotherapist— RUB 6,900.
• Carrying out intravesical chemotherapy (without the cost of medications) - RUB 21,500.
• Intraperitoneal chemotherapy (without the cost of medications) - RUB 19,100.
• Immunotherapy (without the cost of medications) - RUB 15,000.
• Intrathecal chemotherapy - RUB 21,000.
• Carrying out hyperthermic intraperitoneal chemotherapy - 280,000 rubles.
• Chemotherapy using an infusion pump for 1 day (without the cost of medications) - RUB 17,900.
• Carrying out anti-PD-1 therapy - RUB 334,000.

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Contraindications to chemotherapy

All chemotherapy drugs are toxic. And contraindications to their use are in conditions where the use of the medicine will obviously cause harm more than the expected benefit.

• pregnancy;
• cachexia (exhaustion);
• cardiovascular, hepatic, renal failure;
• diabetes mellitus in the stage of decompensation;
• severe anemia (up to 60 g/l hemoglobin);
• leukopenia (the number of leukocytes is less than 3*109/l);
• thrombocytopenia (platelet count less than 1*109/l);
• individual intolerance.

Efficacy of chemotherapy

It is very important for both the doctor and the patient to know how effective the course of treatment was. It is necessary to understand whether the measures taken help prolong or make the patient’s life easier, or whether the treatment brings additional suffering.

Unfortunately, even the most experienced specialist will not be able to give an accurate forecast before the start of the course. The oncologist prescribing treatment assesses how high the chances of a positive result are. But it cannot be ruled out that with a 95% chance of success, a particular patient will fall into the remaining five percent.

But the opposite situations also occur. Cases have been described where, with a 10% chance of success, patients recovered completely. Why does treatment help some patients and not others? It all depends on the reactions of the individual patient’s body.

Advice! Recently, scientists discovered a gene that was called the multiple drug resistance gene. If this gene is present in large quantities in a neoplasm, then it is extremely difficult to cure it with drugs.

Efficiency also depends on the stage of development of the pathology. In the early stages, you can achieve complete recovery, in others - only slightly alleviate the condition.

Targeted therapy for peritoneal cancer

In some cases, doctors prescribe targeted therapy drugs - drugs that act only on cancer cells and do not harm healthy ones. Unfortunately, they are not suitable for everyone.

The doctor orders tests and, based on their results, evaluates whether this type of treatment will help you.

For peritoneal oncology, there are three options for such therapy:

• Monoclonal antibodies that
  target substances that help cancer cells grow. Such drugs include, for example, trastuzumab (Herceptin). It can be used simultaneously with chemotherapy.
• PARP inhibitors,
  which prevent tumor cells from repairing damaged DNA, which leads to their death. One such drug is olaparib (Lynparza).
• Angiogenesis inhibitors,
  or substances that prevent the development of blood vessels that feed the tumor. Such a drug is bevacizumab.

In some cases of primary peritoneal cancer, the following are also used:

• Radiation therapy, which destroys tumor cells using radiation. It is used quite rarely, since usually the area of ​​damage is so large that the side effects of the procedure will outweigh its possible benefits;
• hormonal therapy to slow or stop the growth of cancer;
• and immunotherapy, which helps one’s own immune system better fight cancer.

The main types of treatment remain surgery, chemotherapy and HIPEC.

Treatment of peritoneal cancer and carcinomatosis with HIPEC

HIPEC, or hyperthermic intraperitoneal chemotherapy, is a new treatment for primary peritoneal cancer and carcinomatosis - metastases to the peritoneum from other types of cancer.

When using this method, there is a double effect on cancer cells - heat and chemotherapy drugs, and not on the entire body at once, but pointwise, on the peritoneum itself, exactly where it is needed.

Due to the cost of materials, equipment and the need to train specialists, the method is not cheap, and in our country it is used in a very small number of clinics.

In addition, it is not recommended for metastases outside the abdominal cavity and some other situations.

Diagnosis of peritoneal cancer

Diagnosing peritoneal cancer in the early stages is difficult, partly because of vague symptoms that can signal a wide range of other health problems.

Often this type of cancer is discovered only during surgery to remove a tumor elsewhere in the abdominal cavity.

What tests are included in the diagnosis of peritoneal cancer according to compulsory medical insurance in Russia:

• general detailed blood test;
• biochemical blood test, including indicators of kidney and liver function;
• study of the blood coagulation system;
• general detailed urine analysis;
• study of the level of CA 125 antigen to detect ovarian cancer and its re-development;
• analysis for tumor markers CEA and CA19-9;
• if ovarian cancer is suspected, it is recommended to test for the presence of HE4 in the blood - human epidermal protein 4;
• genetic study of mutations (changes) in the BRCA1 and BRCA2 genes to study the possibility of using immunotherapy;
• At the discretion of the doctor, additional studies may be prescribed.

In addition, the doctor must examine the patient:

• recto-vaginal - will insert fingers into the vagina and rectum and check the condition of the organs;
• palpation (palpation) of the abdominal organs and all groups of lymph nodes;
• listening to the lungs;
• palpation of the mammary glands.

The following studies are also prescribed to diagnose peritoneal cancer:

• esophagogastroduodenoscopy
  - examination of the esophagus, stomach and duodenum. This is necessary in order to exclude tumors and other diseases of the gastrointestinal tract - the esophagus, stomach and duodenum;
• colonoscopy
  - prescribed when the doctor believes that the patient may have ovarian cancer;
• CT scan
  - computed tomography of the abdominal cavity, retroperitoneum, kidneys and chest - this is necessary in order to understand how much the tumor has spread and how best to treat it;
• MRI
  - magnetic resonance imaging of the pelvic organs The pelvis is the lower half of the female pelvis, in which the uterus, ovaries, fallopian tubes, bladder, rectum, vessels and nerves are located to determine the prevalence of oncology and treatment options;
• X-ray of
  the chest organs is needed only when a CT scan is not possible. This will detect additional cancerous tumors in the lungs and lymph nodes;
• Ultrasound
  - Ultrasound examination of the lymph nodes is the easiest way to understand what is happening in the abdomen, pelvis and lymph nodes. The procedure is also prescribed in cases where CT, MRI or PET-CT cannot be performed, as well as for examining the mammary glands;
• laparoscopy
  - examination of the peritoneum and abdominal cavity through small incisions. This procedure helps to thoroughly examine the organs, assess the extent of the damage, determine the stage of the disease and the possibility of surgery.

Before starting treatment, the doctor will give a piece of tumor tissue to the laboratory for examination, where they will determine the structure of its cells and their number in different parts of the body or organs.

How to distinguish peritoneal cancer from ovarian cancer?

Peritoneal cancer is very similar to advanced ovarian cancer because they contain the same type of cells.

Primary peritoneal cancer is a tumor in which:

• the ovaries appear normal (healthy);
• there are no cancer cells on their surface;
• the type of tumor is serous, that is, secreting fluid.