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Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Moderately and Poorly Differentiated Appendiceal Adenocarcinoma: Survival Outcomes and Patient Selection

  • Gastrointestinal Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Moderately and poorly differentiated adenocarcinoma of the appendix represents an aggressive histological variant with a high risk of recurrence and death.

Methods

Overall, 178 patients with moderately and poorly differentiated appendiceal adenocarcinoma were identified from a prospective database. Clinical, pathologic, and treatment factors were analyzed for outcomes.

Results

Diagnostic laparoscopy (DL) identified radiographic occult peritoneal metastasis in 25 (42%) patients. These patients had a significantly lower peritoneal carcinomatosis index (PCI) and improved overall survival (OS) compared with those with radiographic disease. Twenty-seven (41%) patients were excluded from cytoreductive surgery (CRS) because of findings on DL, while 116 (65%) patients underwent CRS and hyperthermic intraperitoneal chemotherapy (HIPEC), with a median disease-free survival (DFS) of 23 months. Mucinous histology (hazard ratio [HR] 0.52, p = 0.04) and PCI (HR 1.054, p = 0.02) were independent predictors of DFS. The median OS following CRS and HIPEC was 48 months. Mucinous histology (HR 0.352, p = 0.018), signet ring cells (HR 3.34, p = 0.02), positive peritoneal cytology (HR 0.081, p = 0.04), and PCI (HR 1.076, p = 0.004) were independently associated with OS. Eight-five (73.3%) patients received neoadjuvant chemotherapy, and 40 (47.1%) patients achieved a radiographic response; 36 (42.3%) had stable disease, while 9 (10.6%) had progressive disease. Stable or responsive disease was associated with improved median OS of 44 months, compared with 21 months for those with progressive disease (p = 0.011).

Conclusions

In selected patients, long-term survival can be obtained. Mucinous histology, absence of signet ring cells, negative peritoneal cytology, PCI ≤ 20, and response/stable disease after neoadjuvant chemotherapy are important selection criteria for CRS and HIPEC.

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Acknowledgment

The authors would like to acknowledge Harold Allen, Sun and Do Lee, and Andrew Shroeder for their contribution to gastrointestinal cancer research at MD Anderson Cancer Center.

Disclosures

Travis E. Grotz, Michael J. Overman, Cathy Eng, Kanwal P. Raghav, Richard E. Royal, Paul F. Mansfield, Gary N. Mann, Kristen A. Robinson, Karen A. Beaty, Safia Rafeeq, Aurelio Matamoros, Melissa W. Taggart, and Keith F. Fournier have no disclosures to declare.

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Authors and Affiliations

  1. Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Travis E. Grotz MD, Richard E. Royal MD, Paul F. Mansfield MD, Gary N. Mann MD, Kristen A. Robinson PA-C, Karen A. Beaty PA-C, Safia Rafeeq MD & Keith F. Fournier MD

  2. Department of Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Michael J. Overman MD, Cathy Eng MD & Kanwal P. Raghav MBBS, MD

  3. Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Aurelio Matamoros MD

  4. Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Melissa W. Taggart MD

Authors
  1. Travis E. Grotz MD
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  2. Michael J. Overman MD
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  3. Cathy Eng MD
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  13. Keith F. Fournier MD
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Corresponding author

Correspondence to Keith F. Fournier MD.

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Grotz, T.E., Overman, M.J., Eng, C. et al. Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Moderately and Poorly Differentiated Appendiceal Adenocarcinoma: Survival Outcomes and Patient Selection. Ann Surg Oncol 24, 2646–2654 (2017). https://doi.org/10.1245/s10434-017-5938-8

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  • DOI: https://doi.org/10.1245/s10434-017-5938-8

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