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Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license.  \n1 Department of Gastrointestinal Surgery, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; [cossu.andrea@hsr.it](cossu.andrea@hsr.it) (A.C.); [rosati.riccardo@hsr.it](rosati.riccardo@hsr.it) (R.R.); [elmore.ugo@hsr.it](elmore.ugo@hsr.it) (U.E.)  \n2 School of Medicine, Vita-Salute San Raffaele University, 20132 Milan, Italy  \n* [Correspondence: puccetti.francesco@hsr.it](Correspondence: puccetti.francesco@hsr.it)[ ](Correspondence: puccetti.francesco@hsr.it)† These authors share the last authorship.  \nSimple Summary  \nPeritoneal metastases from gastric cancer represent one of the most challenging disease presentations, often leading to limited survival and a rapid decline in quality of life. Although modern treatments such as chemotherapy, immunotherapy and targeted therapies have improved outcomes in metastatic gastric cancer overall, they are far less effective when the disease involves the peritoneal cavity. Correct treatment planning must therefore begin with accurate disease assessment, including staging laparoscopy, which can detect hidden peritoneal spread and help avoid unnecessary major surgery. Several innovative locoregional approaches have shown encouraging results in selected patients, but they are not yet fully validated for widespread adoption. Most importantly, we still lack reliable biological indicators to guide treatment selection and match the right approach to the right patient. Continued research is crucial to develop more personalized strategies and improve care for individuals with gastric cancer complicated by peritoneal metastases.  \nAbstract  \nPeritoneal 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 torefine 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.  \nKeywords: gastric cancer; peritoneal metastases; HIPEC; PIPAC; NIPS; chemotherapy  \n1. Editorial  \nPeritoneal involvement remains a common and clinically significant pattern of disease spread in gastric cancer. Its presence profoundly influenc","cbCaigeZLPzVLtvS","https://ap.wps.com/l/cbCaigeZLPzVLtvS","pdf",213235,"English","# Editorial\n## Why Peritoneal Metastases Still Matter\n## Staging as the First Therapeutic Decision","[{\"question\":\"Why do peritoneal metastases still represent a major challenge in gastric cancer?\",\"answer\":\"They are aggressive, therapeutically difficult, and often resistant to systemic therapy. The peritoneal microenvironment limits therapeutic penetration and contributes to early treatment failure and poor survival.\"},{\"question\":\"How does staging laparoscopy influence treatment planning?\",\"answer\":\"Staging laparoscopy is the most sensitive approach to detect radiologically occult peritoneal metastases. It helps prevent non-therapeutic gastrectomies and directs patients toward the appropriate systemic or locoregional pathway.\"},{\"question\":\"What role do locoregional approaches like CRS–HIPEC, PIPAC, and NIPS play?\",\"answer\":\"These strategies expand the therapeutic options for selected patients and have shown encouraging signals. However, broader validation and optimization of patient selection and sequencing remain necessary.\"}]","Current Challenges and Future Directions in the Multimodal Management of Gastric Cancer with Peritoneal Metastases - Editorial | PDF",1790768192,15]