Thanks for the answer.Now I would like to modify the statement if the same can be applied for management without CT or Staging Laparoscopy for managing Ca Stomach especially in countries with limited resources and making treatment cost- effective.Would you like to give your valuable opinion.

In advanced-stage gastric cancer a laparoscopy with peritoneal cytology is mandatory for the correct staging. If it's positive, the patient can be candidate to gastrectomy associated with intraperitoneal chemo (HIPEC); neo-adjuvant chemotherapy is not effective on peritoneal disease

Yes, peritoneal cytology is part of our way of staging gastric carcinoma.

It is fast,easy and reliable in experienced hands.

If the gastric cancer is in advanced stage, the best procedure for staging is the diagnostic laparoscopy together with peritoneal cytology. If it's negative, the patient can be candidate for gastrectomy (subtotal or total) with D2 lymphadenectomy. If it's positive, the only therapeutic procedure is gastrectomy with metastasectomy associated with HIPEC. The results of the neoadjuvant chemotherapy are doubtful in these cases. In countries with limited resourses the preoperative peritoneal tap cytology is helpful for staging.

Yes as mentioned in most of the replies above.

Please see details in some scientific papers such as http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3296804/

--A gastric cancer patient with positive cytology would be stage IV. -------

In the 7th edition of AJCC/UICC cancer staging guidelines the peritoneal cytology has been included as a staging procedure, regardless, how it can be obtained. Positive peritoneal cytology makes the disease stage IV., with all consequences. Unfortunately, this mandatooy procedure (peritoneal cytology) has not infiltrated the clinical practice of surgeons and with missing peritoneal cytology they are used to operate gastric cancer cases without proper staging.

It is good to continue having a healthy debate about this issue.Japanese consider it a part of staging procedure while TNM classification positivity of cytology considers it a stage 4 disease.In clinical practice as referred by one of the friends,how many people really apply it in managing gastric cancer?

It is essential to do peritoneal cytology combined with diagnostic laparoscopy to stage the carcinoma stomach if disease is suspected to be advancedf and usefulness of radical surgery. As positive peritoneal cytology is stage IV disease and only option to be exercised in that patients is gastrectomy with metatasesectomy followed by HIPEC.

"Thanks for the answer.Now I would like to modify the statement if the same can be applied for management without CT or Staging Laparoscopy for managing Ca Stomach especially in countries with limited resources and making treatment cost- effective.Would you like to give your valuable opinion. "

Brief Response:

You may perform peritoneal fluid cytology as it is minimally invasive and relatively inexpensive. If it is positive- manage as Stage IV. If negativ- manage as Stage I, II, or III based on whatever other clinical info helps to stage.

Peritoneal citology is an indispensable part of gastric cancer staging today; it has always been this way if we look at Japanese literature and staging systems, but much more after publication of the 7th edition of TNM, that finally recognizes cy(+) as a criterion for stage IV. There is no other way to assess this than a peritoneal lavage (usually during staging laparoscopy) or ascitic fluid tapping (if ascites present)

Ok, we know that cytology is crucial in the diagnostic process, but the question now is: what method we have to look for cancer cells? Papanicolaou, RT-PCR, immunocytochemistry?

I think the best cytology work-up should include both Giemsa (Romanowsky, Diff Quick, MGG or similar metod) and Papanicolau stains as well as cell block preparation (H&E-stained). In doubtful cases the immunohistochemical stains could be performed, usually monoclonal CEA (if we are still talking about the gastric carcinoma). I don't know how RT-PCR technique could help in the routine work - may be there is something new I am not aware of?

There are many publications on the use of RT-PCR for peritoneal citology in patients with gastric cancer

Do you mean PCR for CEA or aomething else?

If we are talking about CEA in peritoneal fluid I whould like to ask:

1. Is there significant prognostic difference between cases with positive cytology (which include also the cases with equivocal morphology positive for CEA by immunohistochemistry) and RT-PCR?

2. Could we always accept CEA positive by RT-PCR as an obvious sign of malignancy?

I think the answer to your question maybe you can find in the paper of Yonemura "Diagnostic value of preoperative RT-PCR-based screening method to detect carcinoembryonic antigen-expressing free cancer cells in patients with the Peritoneal cavity fron gastric cancer" published on ANZ J. Surg. (2001)

Thank you for the citation. Actually, it raises more questions but it seems to be beyound the scope of this site.

It can obviously. I suppose that if there is no ascites one may do peritoneal lavage the way one does it for Diagnostic Peritoneal Lavage (DPL) in trauma victim. It may not be left to laparoscopy.

Smart guys are working on it... :)

http://www.10igcc.com/how-to-standardize-peritoneal-cytology-2/

Patients having no ascites are subjected to DPL in one of our series of patients indeed to know peritoneal status in ca stomach as an easy way to have preop staging in them..

Routine good pap staining of slides with cell block correlation helps to improve diagnostic accuracy by 10%. We have worked on this as cell block ncan be used also for immunocytological confirmation

The complete staging of gastric cancer must comprise the peritoneal citology; according to Japanese surgeons the positive cancer cells in the peritoneum is a sign of metastatic disease!

And you can use the study with RT-PCR rapid kit (90 minute about) on the peritoneal fluid to detect the CK20 and CEA mRNA expression as metastasis sign!

Dr. Luigi, it is not according to Japanese surgeons, it is according to the recently used staging system....

Yes certainly. Postive cytology undoubtedly associated with worse prognosis and may change decision making for surgery. Those patients are usually recommended for chenotherapy and restaging. If cytology becomes negative could be considered for surgery, if stays positive then prognosis very poor and treatment palliative