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Surgical Innovations in Advanced Gastric Cancer
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Surgical Innovations in Advanced Gastric Cancer

A special issue of Cancers (ISSN 2072-6694). This special issue belongs to the section "Cancer Therapy".

Deadline for manuscript submissions: closed (31 December 2025) | Viewed by 6979

Special Issue Editors

Prof. Ugo Elmore

E-Mail Website
Guest Editor
Gastrointestinal Surgery Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
Interests: colorectal cancer; esofagogastric cancer; minimally invasive treatment
Dr. Francesco Puccetti

E-Mail Website
Guest Editor
Gastrointestinal Surgery Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
Interests: development of clinical and surgical improvements in gastric cancer care; multidisciplinary collaboration for advance gastric cancer care
Dr. Andrea Cossu

E-Mail Website
Guest Editor
Gastrointestinal Surgery Unit, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
Interests: development of clinical and surgical improvements in gastric cancer care; multidisciplinary collaboration for advance gastric cancer care

Special Issue Information

Dear Colleagues,

Advanced gastric cancer represents a challenging and demanding aspect besetting every major national health system worldwide, and the management of metastatic patients is critical, requiring both infrastructural resources and professional involvement.

We are pleased to invite you to share measurable research initiatives that could contribute to this Special Issue of Cancers titled “Surgical Innovations in Advanced Gastric Cancer”. The aim of the present issue is to cover more experience, knowledge and technological advances in the field of advanced gastric cancer surgery. Moreover, this invitation has been sent to you on the basis of your scientific and clinical commitments.

This Special Issue aims to highlight major surgical novelties that have been introduced in advanced gastric cancer care and that are considered promising in changing such a poor prognosis, garnering a collection of ten articles reporting the most relevant experiences in the management of advanced, metastatic, oligometastatic and recurrent gastric cancer.

In this Special Issue, original research articles and reviews are welcome. Research areas may include (but are not limited to) the following:

  • Gastric cancer;
  • Peritoneal metastasis;
  • Advanced oligometastatic-recurrent gastric cancer and palliation;
  • Experimental surgery.

We look forward to receiving your contributions.

Prof. Ugo Elmore
Dr. Francesco Puccetti
Dr. Andrea Cossu
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as communications are invited. For planned papers, a title and short abstract (about 250 words) can be sent to the Editorial Office for assessment.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Cancers is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2900 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

 

Keywords

  • gastric cancer
  • gastrectomy
  • oligometastatic cancer
  • recurrence
  • peritoneal carcinomatosis
  • multimodal management

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Published Papers (5 papers)

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Editorial

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6 pages, 208 KB  
Editorial
Current Challenges and Future Directions in the Multimodal Management of Gastric Cancer with Peritoneal Metastases
by Andrea Cossu, Francesco Puccetti, Riccardo Rosati and Ugo Elmore
Cancers 2026, 18(1), 105; https://doi.org/10.3390/cancers18010105 - 29 Dec 2025
Viewed by 821
Abstract
Peritoneal metastases represent one of the most dreadful manifestations of gastric cancer and continue to drive poor outcomes despite significant advances in systemic therapy. Accurate staging—beginning with laparoscopy—remains essential for avoiding non-beneficial surgery and ensuring appropriate allocation to systemic or locoregional treatment pathways. [...] Read more.
Peritoneal metastases represent one of the most dreadful manifestations of gastric cancer and continue to drive poor outcomes despite significant advances in systemic therapy. Accurate staging—beginning with laparoscopy—remains essential for avoiding non-beneficial surgery and ensuring appropriate allocation to systemic or locoregional treatment pathways. Although modern systemic agents, including immunotherapy and targeted therapies, have transformed the broader management of metastatic disease, their impact in the peritoneal compartment remains limited, reflecting its unique biological and pharmacokinetic constraints. Locoregional approaches such as CRS–HIPEC, PIPAC, and NIPS have expanded the therapeutic armamentarium and have shown encouraging signals in selected populations. Recent randomized studies, including ESTOK01 and PERISCOPE II, emphasize the importance of careful patient selection, technical standardization, and optimal sequencing, while ongoing trials—such as PREVENT, GASTRICHIP, and CONVERGENCE—seek to refine the integration of systemic and intraperitoneal strategies. Yet the field continues to advance without the benefit of validated predictive biomarkers capable of guiding therapeutic decisions. This limitation constrains clinical progress and underscores the need for a stronger translational framework. Future improvement in the management of gastric cancer with peritoneal metastases will depend on the identification of robust biological predictors of response, enabling more rational patient selection and the development of truly personalized multimodal approaches. Full article
(This article belongs to the Special Issue Surgical Innovations in Advanced Gastric Cancer)

Research

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10 pages, 232 KB  
Article
Staging Laparoscopy in High-Risk Gastric Cancer: A Decade of Real-World Evidence and Therapeutic Impact from a Tertiary Referral Center
by Andrea Cossu, Riccardo Calef, Francesco Puccetti, Silvia Foti, Stefano Cascinu, Riccardo Rosati, Ugo Elmore and OSR CCeR Collaborative Group
Cancers 2026, 18(1), 27; https://doi.org/10.3390/cancers18010027 - 21 Dec 2025
Viewed by 1052
Abstract
Background and Aims: Gastric cancer (GC) remains a leading cause of cancer-related mortality, frequently diagnosed at advanced stages. High-risk features—tumor size ≥ 40 mm, cT3/cT4, nodal involvement, diffuse histology, and Borrmann type III/IV—are associated with peritoneal metastasis (PM). Staging laparoscopy with peritoneal washing [...] Read more.
Background and Aims: Gastric cancer (GC) remains a leading cause of cancer-related mortality, frequently diagnosed at advanced stages. High-risk features—tumor size ≥ 40 mm, cT3/cT4, nodal involvement, diffuse histology, and Borrmann type III/IV—are associated with peritoneal metastasis (PM). Staging laparoscopy with peritoneal washing (PW) is superior to conventional preoperative imaging modalities, including contrast-enhanced CT, MRI, PET/CT and endoscopic ultrasound, in detecting occult peritoneal disease. In this era of personalized medicine and expanding loco-regional strategies such as cytoreductive surgery (CRS)/Hyperthermic IntraPEritoneal Chemotherapy (HIPEC) and Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC), accurate staging is crucial. This study assessed the impact of SL and PW in high-risk GC. Methods: We retrospectively analyzed 113 consecutive high-risk GC patients who underwent SL and PW between 2014 and 2024 at our institution. The primary endpoint was detection of PM or positive cytology (CY+). Secondary endpoints were treatment modification, eligibility for loco-regional therapy, and safety. Results: SL/PW identified PM or CY+ in 26 patients (23%), including 16 with CY+ only. None had radiologic signs of peritoneal disease. SL findings altered treatment in all cases: 21 patients (81%) with Peritoneal Cancer Index (PCI) < 6 underwent induction chemotherapy followed by CRS + HIPEC; 5 patients (PCI > 6) were spared non-therapeutic laparotomy and treated with bidirectional systemic chemotherapy and PIPAC. In 10 patients, systemic therapy was shifted from FLOT (fluorouracil, leucovorin, oxaliplatin, and docetaxel) to FOLFOX (fluorouracil, leucovorin, and oxaliplatin) ± nivolumab. No perioperative complications occurred; all patients were discharged within 24 h without delay in systemic treatment. Conclusions: SL with PW is safe and significantly improves staging accuracy in high-risk GC, enabling personalized therapeutic planning. Routine integration of SL should be considered essential in treatment algorithms to guide systemic and loco-regional strategies. Full article
(This article belongs to the Special Issue Surgical Innovations in Advanced Gastric Cancer)
15 pages, 1811 KB  
Article
Modified Proximal Gastrectomy and D2 Lymphadenectomy Is an Oncologically Sound Operation for Locally Advanced Proximal and GEJ Adenocarcinoma
by Emily L. Siegler and Travis E. Grotz
Cancers 2025, 17(15), 2455; https://doi.org/10.3390/cancers17152455 - 24 Jul 2025
Viewed by 3537
Abstract
Background: Proximal gastrectomy (PG) with double tract reconstruction (DTR) offers organ preservation for early gastric cancers, leading to reduced vitamin B12 deficiency, less weight loss, and improved quality of life. The JCOG1401 study confirmed excellent long-term outcomes for PG in stage I gastric [...] Read more.
Background: Proximal gastrectomy (PG) with double tract reconstruction (DTR) offers organ preservation for early gastric cancers, leading to reduced vitamin B12 deficiency, less weight loss, and improved quality of life. The JCOG1401 study confirmed excellent long-term outcomes for PG in stage I gastric cancer. However, in locally advanced proximal gastric cancer (LAPGC), preserving the gastric body and lymph node station 4d may compromise margin clearance and adequate lymphadenectomy. Methods: We propose a modified PG that removes the distal esophagus, gastroesophageal junction (GEJ), cardia, fundus, and gastric body, preserving only the antrum and performing DTR. Lymphadenectomy is also adapted, removing stations 1, 2, 3a, 4sa, 4sb, 4d, 7, 8, 9, 10 (spleen preserving), 11, and lower mediastinal nodes (stations 19, 20, and 110), while preserving stations 3b, 5, and 6. Indications for this procedure include GEJ (Siewert type II and III) and proximal gastric cancers with ≤2 cm distal esophageal involvement and ≤5 cm gastric involvement. Results: In our initial experience with 14 patients, we achieved R0 resection in all patients, adequate lymph node harvest (median 24 nodes, IQR 18–38), and no locoregional recurrences at a median follow-up of 18 months. We also found favorable postoperative weight loss, reflux, and anemia in the PG cohort. Conclusion: While larger studies and long-term data are still needed, our early results suggest that modified PG—despite sparing only the antrum—retains the key benefits of PG over total gastrectomy, including better weight maintenance and improved hemoglobin levels, while maintaining oncologic outcomes for LAPGC. Full article
(This article belongs to the Special Issue Surgical Innovations in Advanced Gastric Cancer)
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Review

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15 pages, 601 KB  
Review
Intraoperative Peritoneal Lavage for Detection of Malignant Cells: Technique, Evidence, Clinical Relevance and Future Perspectives
by Resa Puffert, Anna Quarder, Fabian Kockelmann, Thomas Wirth, Tanja Reineke-Plaaß, Mieke Raap, Moritz Schmelzle, Linda Feldbrügge, Beate Rau and Franziska Köhler
Cancers 2026, 18(10), 1604; https://doi.org/10.3390/cancers18101604 (registering DOI) - 14 May 2026
Viewed by 193
Abstract
Background/Objectives: Peritoneal metastases represent a common manifestation of advanced gastrointestinal malignancies and are associated with poor survival. Their early detection is essential for adequate tumor staging, prognosis, and treatment selection, especially to avoid unnecessary surgery. Intraoperative peritoneal lavage has been established as a [...] Read more.
Background/Objectives: Peritoneal metastases represent a common manifestation of advanced gastrointestinal malignancies and are associated with poor survival. Their early detection is essential for adequate tumor staging, prognosis, and treatment selection, especially to avoid unnecessary surgery. Intraoperative peritoneal lavage has been established as a diagnostic tool to detect occult peritoneal disease. However, reported techniques, analytical methods, and detection rates vary considerably. The objective of this review was to summarize current approaches to intraoperative peritoneal lavage, evaluate different detection methods, and assess their clinical relevance. Methods: A literature search was performed using the PubMed database for studies published between 2015 and 2025. The search terms “intraoperative peritoneal lavage” or “peritoneal fluid cytology” were used. Studies were included if they evaluated peritoneal lavage as a diagnostic method for detecting malignant cells, including all primary tumors and disease stages. Articles focusing on lavage as a therapeutic intervention or lacking methodological details were excluded. Results: Physiological saline solution was used for lavage in all included studies, with volumes ranging from 10 to 1000 mL. Sampling was predominantly performed immediately after abdominal access in various abdominal sites. Detection methods varied widely, with conventional cytology being most frequently used, while molecular techniques were used in a smaller number of studies. Positive detection rates showed broad variations and were higher in advanced tumor stages. Conventional cytology showed limited detection rates compared to molecular approaches. Conclusions: Intraoperative peritoneal lavage remains a valuable but methodologically heterogeneous diagnostic tool with limited detection rates when relying on conventional cytology alone. Molecular techniques seem to improve the detection rate of occult peritoneal disease but require further standardization and validation before routine clinical implementation. The technique of peritoneal lavage should be standardized by implementing an international consensus including lavage sites, volume of applied fluid, and detection method. Full article
(This article belongs to the Special Issue Surgical Innovations in Advanced Gastric Cancer)
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22 pages, 833 KB  
Review
DNA Methylation in Gastric Cancer and Preneoplastic Lesions: Emerging Insights and Future Directions
by Carlotta Ceccon, Giulia Maddalena, Valentina Angerilli, Floriana Nappo, Jessica Gasparello, Marianna Sabbadin, Luisa Toffolatti, Francesca Bergamo, Matteo Fassan and Sara Lonardi
Cancers 2026, 18(7), 1075; https://doi.org/10.3390/cancers18071075 - 26 Mar 2026
Viewed by 823
Abstract
Gastric cancer (GC) represents one of the most common and lethal cancers worldwide. The lack of early detection methods and wide heterogeneity from both histopathological and molecular points of view contribute to the high mortality associated with GC. Nowadays, the growing interest in [...] Read more.
Gastric cancer (GC) represents one of the most common and lethal cancers worldwide. The lack of early detection methods and wide heterogeneity from both histopathological and molecular points of view contribute to the high mortality associated with GC. Nowadays, the growing interest in the epigenetic landscape appears to represent a promising approach for improving early diagnosis, disease monitoring, therapy selection, and drug response. The knowledge of the epigenetic landscape in cancerous and, especially in precancerous lesions, remain scarce and controversial. The limitations must be identified due to the lack of standardization in experimental settings which introduce bias and lead to discrepancies in final conclusions. This review aims to provide an overview of epigenetics in the diagnostic setting of gastric cancer and in preneoplastic conditions, illustrating the available experimental approaches and therapeutic management in the era of epigenetics. Full article
(This article belongs to the Special Issue Surgical Innovations in Advanced Gastric Cancer)
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