ASO Author Reflections: PCI is Not Predictive of Survival After Complete CRS/HIPEC for High-Grade Appendiceal Primaries
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In colon cancer carcinomatosis treated with CRS/HIPEC, a PCI above 17 is associated with survival that is not different from the survival obtained from best supportive care.1 It was unknown to us whether there is a similar PCI limit for HGA primaries, above which even a complete CRS is not offering the patient a survival benefit.2
PCI, either when analyzed at arbitrary cutoff points or as a continuous variable, was not a predictor of survival after complete CRS/HIPEC. Survival was dependent on completion of CRS and not PCI. A CC1 resection in HGA primaries should not be regarded as a complete cytoreduction, because it has similar survival outcomes with a CC2 resection.
The importance of PCI is it that it can predict in a linear fashion who is the patient who will achieve a CC0 resection. In this cohort, only 31% of the patients with a PCI ≥ 21 had a complete cytoreduction.3 These findings suggest that PCI can be viewed as a key indicator of the ability to achieve a complete resection, which ultimately predicts the ability to affect survival.
The above analysis was performed categorizing HGA based on Bradley’s classification and subgroup analysis of patients with positive nodes, lymphovascular invasion, or signet ring features was not possible.4
The current classification of low- and high-grade appendiceal primaries lumps together tumors with great variability in clinical behavior. This is almost a universal problem for all light microscopy-based classifications or even staging systems. With advances in biomedical engineering and sequencing, we are slowly moving from cohort-based analysis to interactive ex vivo personalized study of patient’s individual tumors in the lab. We are currently entertaining for the first time the possibility of a future, that for every patient who presents with appendiceal cancer, we will be able grow its own tumor organoids and decide what is the best course and timing of action in a prospective fashion.5