Gastric cancer with minimal peritoneal metastasis: is this a sign to give up or to treat more aggressively?

Peritoneal metastasis from gastric cancer is often undetectable by routine imaging studies. Even a microscopic metastasis detected only by cytologic examination of the peritoneal washes denotes a dismal prognosis, and surgery is ruled out as futile for patients who turn out to be cytology-positive by staging laparoscopy. On the other hand, recent developments in cancer chemotherapy have improved the outcome of the cytology-positive population to the point where a certain proportion of these patients survive for 5 years through a straightforward strategy of radical surgery followed by chemotherapy. Thus, there is certainly a role for surgeons in patients with minimal peritoneal metastasis, both in clinical practice and in clinical trials where multimodal treatment strategies including surgery are to be explored. Even in this category of patients, surgery in combination with various types of chemotherapy remains the only hope for a cure.