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Should We Be Doing Cytoreductive Surgery with HIPEC for Signet Ring Cell Appendiceal Adenocarcinoma? A Study from the US HIPEC Collaborative

  • 2019 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background

Appendiceal adenocarcinoma with signet ring cells (SCA) is associated with worse overall survival (OS), and it is unclear whether cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) should be pursued in this patient population. We assessed the prognostic implications of signet ring cells in patients with appendiceal adenocarcinoma and peritoneal carcinomatosis undergoing CRS-HIPEC.

Methods

The US HIPEC Collaborative, a 12-center, multi-institutional database of patients undergoing CRS-HIPEC, was reviewed for patients with SCA. Univariate and multivariate analyses were performed.

Results

Of 514 patients undergoing CRS-HIPEC for appendiceal adenocarcinoma, 125 (24%) had SCA. The SCA and non-SCA groups had similar baseline characteristics. SCA had worse OS compared with non-SCA (32.0 vs 91.4 months, p < 0.001). In univariate analysis for only SCA cases, there was worse OS in patients with poorly differentiated tumors, positive lymph nodes, LVI, PCI > 20, or incomplete cytoreduction (CC-2/3). However, multivariate analysis showed only positive lymph nodes (HR 1.14 [95% CI 1.00–1.31], p = 0.04), poor differentiation (5.60 [1.29–24.39], p = 0.02), and incomplete cytoreduction (4.90 [1.11–12.70], p = 0.03) were independently associated with decreased OS for SCA.

Conclusion

While signet cells are a negative prognostic feature, they should not be a contraindication to CRS-HIPEC in patients with well-moderately differentiated tumors with negative lymph nodes, where complete cytoreduction can be achieved.

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Authors and Affiliations

  1. Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML-0558, Cincinnati, OH, 45267-0558, USA

    Nick C. Levinsky, Mackenzie C. Morris, Koffi Wima, Jeffrey J. Sussman, Syed A. Ahmad & Sameer H. Patel

  2. Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA

    Jordan M. Cloyd & Charles Kimbrough

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

    Keith Fournier & Andrew Lee

  4. Department of Gastrointestinal Oncology, Moffitt Cancer Center, Department of Oncologic Sciences, Morsani College of Medicine, Tampa, FL, USA

    Sean Dineen & Sophie Dessureault

  5. Division of Surgical Oncology, Department of Surgery, University of California, San Diego, CA, USA

    Jula Veerapong & Joel M. Baumgartner

  6. Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA

    Callisia Clarke

  7. Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA

    Mohammad Y. Zaidi, Charles A. Staley & Shishir K. Maithel

  8. Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA

    Jennifer Leiting & Travis Grotz

  9. Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA

    Laura Lambert & Ryan J. Hendrix

  10. Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA

    Sean Ronnekleiv-Kelly & Courtney Pokrzywa

  11. Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA

    Mustafa Raoof & Oliver S. Eng

  12. Department of Surgery, Johns Hopkins University, Baltimore, MD, USA

    Fabian M. Johnston & Jonathan Greer

Authors
  1. Nick C. Levinsky
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  2. Mackenzie C. Morris
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  3. Koffi Wima
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  5. Syed A. Ahmad
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  9. Andrew Lee
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  13. Joel M. Baumgartner
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  14. Callisia Clarke
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  15. Mohammad Y. Zaidi
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  16. Charles A. Staley
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  18. Jennifer Leiting
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  20. Laura Lambert
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  27. Jonathan Greer
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  28. Sameer H. Patel
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Contributions

Nick C Levinsky MD: Data collection, statistical analysis, manuscript preparation

Mackenzie C Morris MD: Data collection, statistical analysis, manuscript preparation

Koffi Wima MS: Statistical analysis

Jeffrey J Sussman MD: Provision of patients, critical review of the manuscript

Syed A Ahmad MD: Provision of patients, critical review of the manuscript

Jordan M Cloyd MD: Provision of patients, critical review of the manuscript

Charles Kimbrough MD: Provision of patients, critical review of the manuscript

Keith Fournier MD: Provision of patients, critical review of the manuscript

Andrew Lee MD: Provision of patients, critical review of the manuscript

Sean Dineen MD: Provision of patients, critical review of the manuscript

Sophie Dessureault MD PhD: Provision of patients, critical review of the manuscript

Jula Veerapong MD: Provision of patients, critical review of the manuscript

Joel M Baumgartner MD MAS: Provision of patients, critical review of the manuscript

Callisia Clarke MD: Provision of patients, critical review of the manuscript

Mohammad Y Zaidi MD MS: Provision of patients, critical review of the manuscript

Charles A Staley MD: Provision of patients, critical review of the manuscript

Shishir K Maithel MD: Provision of patients, critical review of the manuscript

Jennifer Leiting MD: Provision of patients, critical review of the manuscript

Travis Grotz MD: Provision of patients, critical review of the manuscript

Laura Lambert MD: Provision of patients, critical review of the manuscript

Ryan J Hendrix MD: Provision of patients, critical review of the manuscript

Sean Ronnekleiv-Kelly MD: Provision of patients, critical review of the manuscript

Courtney Pokrzywa MD: Provision of patients, critical review of the manuscript

Mustafa Raoof MD: Provision of patients, critical review of the manuscript

Oliver S Eng MD: Provision of patients, critical review of the manuscript

Fabian M Johnston MD MHS: Provision of patients, critical review of the manuscript

Jonathan Greer MD: Provision of patients, critical review of the manuscript

Sameer H Patel MD: Study design, provision of patients, statistical analysis, manuscript preparation

Corresponding author

Correspondence to Sameer H. Patel.

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The authors declare that they have no conflict of interest.

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Presentation

The Presidential Plenary Session at 60th Annual Meeting of The Society for Surgery of the Alimentary Tract, May 19, 2019, San Diego, California.

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Levinsky, N.C., Morris, M.C., Wima, K. et al. Should We Be Doing Cytoreductive Surgery with HIPEC for Signet Ring Cell Appendiceal Adenocarcinoma? A Study from the US HIPEC Collaborative. J Gastrointest Surg 24, 155–164 (2020). https://doi.org/10.1007/s11605-019-04336-4

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