Disseminated peritoneal adenomucinosis and peritoneal mucinous carcinomatosis. A clinicopathologic analysis of 109 cases with emphasis on distinguishing pathologic features, site of origin, prognosis, and relationship to "pseudomyxoma peritonei"

COX-2 expression in pseudomyxoma peritonei

COX-2 expression was studied using an immunohistochemical method in 75 patients with pseudomyxoma peritonei (PMP). Twenty-five patients presented with disseminated peritoneal adenomucinosis (DPAM) and 50 with peritoneal mucinous carcinomatosis (PMCA). COX-2 was expressed in neoplastic mucinous epithelium of 30 cases (40%): 20 in PMCA (40%), 10 in DPAM (40%). Weak COX-2 expression was also noted in four of five patients with appendiceal mucinous neoplasms without peritoneal dissemination. In addition, COX-2 was detected in stromal, endothelial, inflammatory cells and reactive mesothelium. This preliminary information indicates a potential for the use of COX-2 inhibitors in patients with PMP.

Toxicity and mortality of cytoreduction and intraoperative hyperthermic intraperitoneal chemotherapy in pseudomyxoma peritonei--a report of 103 procedures

AIMS

To report on treatment related toxicity and mortality in patients with pseudomyxoma peritonei (PMP) treated by cytoreduction in combination with intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) and to identify prognostic factors.

METHODS

A review was performed of 103 procedures of cytoreduction and intraoperative HIPEC for PMP between 1996 and 2004. Toxicity was graded according to the National Cancer Institute Common Toxicity Criteria (NCI CTC) classification. A surgical complication was defined as any post-operative event that needed re-intervention. Pre and peroperative factors were studied on their relationship to toxicity and mortality.

RESULTS

The median hospital stay was 21 days (4-149) with a treatment related toxicity of 54% and a 30 days mortality of 3%. In univariate analysis, toxicity was associated with abdominal tumour load (p<0.01), completeness of cytoreduction (p<0.01), and age (p=0.05). Surgical complications, mainly small bowel perforations/suture leaks, were the main cause of toxicity. A favourable pathology decreased mortality.

CONCLUSIONS

Cytoreduction in combination with intraoperative HIPEC in PMP patients is a treatment with a relatively high toxicity, but a considerable long-term survival in selected patients. Toxicity is mainly surgery related. Concentration of cases to acquire sufficient experience and better selection on age, pathology, and extent of disease is essential to reduce treatment related toxicity and mortality.

Pseudomyxoma peritonei: unusual origin from an ovarian mature cystic teratoma

Pseudomyxoma peritonei (PMP) is classified into pathologically and prognostically distinct categories, such as disseminated peritoneal adenomucinosis (DPAM) and peritoneal mucinous carcinomatosis. There is overwhelming evidence that DPAM arises from a mucinous adenoma of the appendix. The one exception to this is the presentation of a mature ovarian cystic teratoma as PMP where the appendix is normal. This report describes such a case and discusses the presentation, histopathology, and treatment options.

Appendiceal mucinous tumors and pseudomyxoma peritonei: histologic features, diagnostic problems, and proposed classification

Pseudomyxoma peritonei is an overused and underspecified condition that has garnered much attention in the historic literature. In recent years, this condition has been convincingly linked to appendiceal mucinous neoplasms, yet there has been insufficient attention to the histologic characteristics, classification, and differential diagnostic considerations of these neoplasms when encountered by the surgical pathologist. This review provides a coherent approach to the diagnosis and classification of appendiceal mucinous tumors and the peritoneal implants associated with the pseudomyxoma peritonei syndrome with emphasis on differential diagnostic considerations and recommendations for the final pathology report.

Chronic abdominal pain secondary to a mucous cystadenoma of the appendix in a 10-year-old boy

Mucocele of the appendix is a thin-walled dilated appendix filled with mucus. It occurs secondary to chronic obstruction of the appendiceal lumen because of a range of pathologies. Cystadenomas in children are exceedingly rare and most frequently of ovarian origin. A mucous cystadenoma of the appendix in a 10-year-old boy with chronic abdominal pain is presented.

Metastatic neoplasms involving the ovary: a review with an emphasis on morphological and immunohistochemical features

The ovary is a common site of metastatic tumour. In many cases of ovarian metastasis there is a known history of malignancy but in other cases the ovarian tumour is the first manifestation of disease. In this review metastatic colorectal, appendiceal, gastric, breast, pancreatic and biliary tract, hepatocellular, renal, transitional and cervical carcinomas and metastatic malignant melanoma involving the ovary are discussed, as is the issue of synchronous ovarian and endometrial carcinomas. Peritoneal tumours, including primary peritoneal carcinoma, mesothelioma and intra-abdominal desmoplastic small round cell tumour, involving the ovary are also discussed, together with a variety of other rare, metastatic ovarian neoplasms. Many metastatic adenocarcinomas involving the ovary, especially those exhibiting mucinous differentiation, closely mimic primary ovarian adenocarcinomas with morphologically bland areas simulating benign and borderline cystadenoma. This is referred to as a maturation phenomenon. In recent years immunohistochemistry, especially but not exclusively differential cytokeratin (CK7 and CK20) staining, has been widely used as an aid to distinguish between a primary and secondary ovarian adenocarcinoma. While immunohistochemistry undoubtedly has a valuable role to play and is paramount in diagnosis in some cases, the results must be interepreted with caution, especially in mucinous tumours, and within the relevant clinical context. We feel the significance of differential cytokeratin staining is not always understood by histopathologists and this can result in erroneous interpretation. We critically discuss the value of immunohistochemistry and associated pitfalls with each tumour type described.

Serosal involvement in gastrointestinal cancer: its assessment and significance

There is an increasing burden upon diagnostic histopathologists to identify accurately factors of prognostic and therapeutic implication in gastrointestinal cancer. It is perhaps partly because of the use of rigid sequential staging systems, such as the Dukes' classification, that some factors, perhaps most notably involvement of surgical margins (especially in rectal cancer) and serosal involvement (particularly in oesophageal, colonic and rectal cancer), have been relatively neglected until more recently. This is surprising and concerning because both of these pathologically derived parameters strongly correlate with subsequent locoregional recurrence and, ultimately, with prognosis. Whilst the occurrence and significance of serosal involvement have been well recognized in gastric cancer for many years, relatively little attention has been paid to the phenomenon in oesophageal cancer and yet both pleural and peritoneal involvement may be comparatively commonly identified in oesophageal cancer. Serosal involvement and transperitoneal spread are also of considerable prognostic importance in primary appendiceal carcinoma. Only more recently has the significance of serosal involvement been appreciated in colonic and rectal cancer. In the colon, the phenomenon is now recognized to be one of the most important factors in predicting transperitoneal spread and overall prognosis. Furthermore, there is increasing interest in alternative novel strategies, including intraperitoneal chemotherapy and radical peritoneal surgery, as legitimate therapeutic options in many gastrointestinal cancers.

Serous and mucinous borderline (low malignant potential) tumors of the ovary

The prognosis for stage I serous borderline ovarian tumors (SBOTs) is thought to be excellent, despite rare, late recurrences. The behavior of advanced-stage SBOTs primarily depends on the invasiveness vs noninvasiveness of associated extraovarian implants. Pelvic and abdominal lymph node involvement and foci of microinvasion do not seem to adversely affect prognosis. Serous tumors with a micropapillary and/or cribriform growth pattern seem to be more frequently bilateral and exophytic and manifest at an advanced stage with a higher incidence of invasive implants than typical SBOTs. Molecular data suggest that such tumors may represent an intermediate stage in the typical SBOT-invasive low-grade serous carcinoma progression. Limited experience with endocervical (müllerian)-type mucinous borderline tumors shows a possible relation to SBOTs in clinicopathologic features and biologic behavior Intestinal-type mucinous borderline ovarian tumors (I-MBOTs) and well-differentiated mucinous carcinomas manifest at stage I in most cases; the prognosis is excellent. Mucinous tumors associated with pseudomyxoma peritonei are almost always secondary to similar tumors of the appendix or other gastrointestinal sites and should not be diagnosed as high-stage I-MBOTs. Rare primary ovarian mucinous tumors associated with pseudomyxoma peritonei are those arising in mature cystic teratomas. Advanced-stage ovarian mucinous carcinomas typically show frank, infiltrative-type invasion; the prognosis is poor.

Intraperitoneal hyperthermic chemotherapy for peritoneal surface malignancy: current status and future directions

Natural history studies have shown that peritoneal carcinomatosis is uniformly fatal, with a median survival in the range of approximately 6 months. For more than a decade, a handful of centers have pursued aggressive intraperitoneal cytoreductive surgery combined with intraperitoneal hyperthermic chemotherapy as an alternative approach to this disease. Strict selection criteria, variation in intraperitoneal chemotherapy, and the vagaries of what represents "cytoreductive surgery" make many of our colleagues, particularly those in medical oncology, reticent to refer patients for such an aggressive therapy. This article establishes a conceptual framework for understanding the role of intraperitoneal hyperthermic chemotherapy in the treatment of peritoneal surface malignancy. This procedure continues to make advancements in the oncological community despite formidable challenges. The advancement of centers of excellence and the initiation of further phase II trials will help to define the optimal treatment approach for peritoneal carcinomatosis.

Pharmacokinetic changes induced by the volume of chemotherapy solution in patients treated with hyperthermic intraperitoneal mitomycin C

BACKGROUND

The rationale supporting the use of intraperitoneal chemotherapy in peritoneal surface malignancy relates to a large local-regional effect and low systemic toxicity. While optimizing the use of this treatment strategy, little information regarding the effect of volume of chemotherapy solution is available.

OBJECTIVE

The goal of this study was to provide data regarding the effect of volume of chemotherapy solution on the pharmacokinetics of intraperitoneal chemotherapy. Data by which to optimally adjust this parameter during intraperitoneal chemotherapy treatments were sought.

METHODS

Forty-eight patients with peritoneal surface malignancy were treated with hyperthermic intraperitoneal mitomycin C chemotherapy after a complete cytoreduction to remove all visible evidence of mucinous tumor. The dose of mitomycin C was always 12.5 mg/m(2) in males and 10 mg/m(2) in females. The first 12 patients were treated with 6 l of 1.5% dextrose peritoneal dialysis solution. The next 14 patients were treated with 4 l of fluid and then ten patients were treated with 2 l. In the last 12 patients the volume of fluid was 1.5 l/m(2) . Blood, peritoneal fluid, and urine samples were obtained every 15 min for 90 min; additional blood and urine samples were obtained at 120 min. Mitomycin C concentrations, urine volumes, and final intraperitoneal fluid volume were obtained.

RESULTS

The intraperitoneal and the plasma concentrations were highest in the 2-l group, less in the 4-l group, and least in the 6-l group. All differences were statistically significant. Also, the percent of mitomycin C absorbed decreased significantly from 2, to 4, to 6 l of fluid. The area under the curve (AUC) ratio of intraperitoneal concentration times time to intravenous concentration times time was 27.01+/-4.92 for 2 l, 22.22+/-7.95 for 4 l, and 24.01+/-8.46 for 6 l. These differences were not statistically significant. If both the volume of chemotherapy solution and the total dose of mitomycin C were determined from the body surface area, the pharmacokinetics of intraperitoneal mitomycin C were more consistent.

CONCLUSIONS

In order to prescribe a uniform treatment for patients receiving hyperthermic intraperitoneal mitomycin C, the total dose of the drug and the total volume of chemotherapy solution should be determined from the body surface area. If the volume of chemotherapy solution is not based on patient body surface area, predictions regarding toxicity are less precise.

Invasion patterns in stage I endometrioid and mucinous ovarian carcinomas: a clinicopathologic analysis emphasizing favorable outcomes in carcinomas without destructive stromal invasion and the occasional malignant course of carcinomas with limited destructive stromal invasion

Stage I, low-grade endometrioid and mucinous ovarian carcinomas have an excellent prognosis. Published data have suggested that destructive stromal invasion, a relatively uncommon finding in these tumors, is a poor prognostic factor. We investigated this by studying all FIGO stage I, grades 1 and 2 (of 3) endometrioid and mucinous ovarian carcinomas that were surgically staged at the Memorial Sloan-Kettering Cancer Center from 1980 to 2000. We undertook a careful review of all available slides using current diagnostic criteria and correlated histopathologic indices with clinical outcome data. Cases studied included 13 endometrioid ovarian carcinomas (stage IA, eight; stage IC, five) and six intestinal mucinous ovarian carcinomas (stage IA, three; stage IC, three). All of the tumors contained areas of expansile invasion, greater than that acceptable for microinvasion, and were thus diagnosed as carcinomas instead of borderline tumors. Nevertheless, nearly all demonstrated borderline tumor (noninvasive) components. Six tumors contained at least one focus of destructive stromal invasion (two endometrioid and four mucinous ovarian carcinomas). Four additional cases showed a focus suspicious for but not diagnostic of destructive invasion ('indeterminate for destructive invasion') (two endometrioid and two mucinous ovarian carcinomas). Follow-up data were available for 17 patients. The median follow-up was 81 months (range, 9-161 months). In all, 14 patients were alive with no evidence of disease (expansile invasion alone, eight; destructive stromal invasion, four; and indeterminate for destructive invasion, two). Three patients died of their disease (destructive stromal invasion, two; and indeterminate for destructive invasion, one). The size, number, and nuclear grade of destructive stromal invasion foci did not appear to have an impact on survival in this relatively limited number of patients. Outcome data in patients with stage I, low-grade endometrioid and mucinous ovarian carcinomas without destructive stromal invasion indicate that these tumors have a very limited malignant potential. The literature has not documented recurrences in this setting when the staging has been complete, the sampling adequate, and the cytologic features no more than grade 2, and metastasis to the ovary has been excluded. In contrast, carcinomas harboring even limited foci of destructive stromal invasion, although frequently cured surgically, can pursue a malignant clinical course.

Cytoreductive surgery with intraperitoneal chemohyperthermia for the treatment of pseudomyxoma peritonei: a prospective study

PURPOSE

Pseudomyxoma peritonei is a rare disease. Recently, cytoreductive surgery with intraperitoneal hyperthermic chemotherapy has emerged as a promising treatment for this debilitating condition. The aim of this prospective study was to evaluate this treatment strategy.

METHOD

Twenty-seven patients with pseudomyxoma peritonei who were treated by cytoreductive surgery and intraperitoneal chemohyperthermia between 1997 and 2003 were identified from a prospective database.

RESULTS

Clinical presentation included suspected appendicitis (33 percent), increased abdominal girth (30 percent), and a suspected ovarian mass (26 percent). Twenty-two patients underwent surgery elsewhere before referral. Seventeen complications occurred in 12 patients (44 percent). Six were considered major: three anastomotic leaks, two pleural effusions, and one intra-abdominal abscess. Histologic examination demonstrated Grade 1, 2, and 3 disease in 8 (30 percent), 10 (37 percent), and 9 patients (33 percent), respectively. Pathologic grade showed a significant influence on the complication rate (P = 0 0.008). The actuarial five-year survival was 100 percent for patients with Grade 1 disease, whereas actuarial one-, two-, three-, and five-year survival for Grades 2 and 3 were 100, 80, 64, and 32 percent, respectively (P = 0.008).

CONCLUSIONS

Cytoreductive surgery with intraperitoneal hyperthermic chemotherapy is a feasible treatment for pseudomyxoma peritonei. It is associated with acceptable morbidity when performed by an experienced surgical team. Histologic grade is the major determinant of survival.

Pseudomyxoma peritonei and selected other aspects of the spread of appendiceal neoplasms

The varied aspects of spread of appendiceal neoplasms are reviewed with emphasis on the often clinically dramatic phenomenon known as pseudomyxoma peritonei, a term mostly used to describe grossly evident mucin within the peritoneal cavity. The majority of cases of pseudomyxoma peritonei result from tumors primary in the appendix, which are usually low-grade. On microscopic examination pseudomyxoma peritonei is typically characterized by large aggregates of mucin which may be relatively acellular or cellular containing strips of mucinous epithelium, mucinous epithelium encircling glands and cysts, or aggregates of mucinous epithelium lying within mucin pools. High-grade adenocarcinoma of the appendix may spread to the omentum and peritoneal surfaces without grossly striking mucin deposition and resemble spread of other high-grade gastrointestinal adenocarcinomas. In many cases of pseudomyxoma peritonei in females there is involvement of one, or more often, both ovaries. The size of the ovarian neoplasms characteristically dwarfs the often relatively unremarkable appearing appendix in these cases. The ovaries are typically multilocular, although one locule may dominate, and in cases in which the primary is a low-grade appendiceal mucinous neoplasm often have a "jelly-like" consistency. In cases of spread of frank adenocarcinomas the ovarian metastases typically have a more solid, albeit still somewhat gelatinous consistency. Microscopic examination of the ovaries typically shows surface involvement, a characteristic of spread to the ovaries in general, and the glands and cysts that replace most or all of the parenchyma are typically lined by tall mucin-rich cells with, in many cases, relatively bland microscopic features. In cases of frank adenocarcinoma, the tumors may mimic closely a primary mucinous adenocarcinoma of the ovary. Spread to the ovaries may also be seen in cases of frank intestinal-type adenocarcinoma primary in the appendix and the uncommon signet ring cell carcinoma of the appendix, the latter being one cause of the Krukenberg tumor. Occasional cases are reported in the literature of ovarian spread of goblet cell carcinoid tumor of the appendix, but in our opinion most of the primary tumors in those cases are better classified as adenocarcinomas, usually dominantly of signet-ring cell type, albeit sometimes with focal neuroendocrine differentiation. Other interesting aspects of spread of appendiceal neoplasms include to the lining of the uterus and the fallopian tube. In yet other cases the tumors may present clinically as incidentally discovered mucinous aggregates within hernia sac specimens or as a scrotal mass.

Synchronous extraperitoneal and intraperitoneal dissemination of appendix cancer

BACKGROUND

The aim of this study was to report the role of combined treatments, including cytoreductive surgery and perioperative regional chemotherapy, in patients with synchronous systemic and intraperitoneal dissemination of appendix cancer.

METHODS

Patients with synchronous systemic and intraperitoneal dissemination of appendix cancer were treated with cytoreductive surgery and perioperative regional chemotherapy. Variables statistically analyzed with survival as an end point included demographic characteristics, prior surgical score (PSS), tumour marker levels, peritoneal cancer index (PCI), and completeness of cytoreduction (CC).

RESULTS

Mean follow up was 42.6 months, median survival time (MST) for 15 patients was 28 months and 5-year survival rate was 29.4%. Female patients had a longer MST than male patients (p=0.0199). Survival was better in patients with PSS 0 and 1 (p=0.0277). Patients with elevated CEA and CA 19-9 levels had a shorter MST (p=0.0083 and p=0.0193, respectively). PCI and CC comparisons did not show significant differences. Morbidity (n=2) and mortality (n=2) rates were 13.3% respectively.

CONCLUSION

Acceptable morbidity and mortality and a 29.4% 5-year survival rate allows cytoreductive surgery and regional chemotherapy to be considered as a treatment option for selected patients with synchronous systemic and intraperitoneal dissemination of appendix cancer.

Long-term survival following treatment of pseudomyxoma peritonei: an analysis of surgical therapy

SUMMARY BACKGROUND DATA

Pseudomyxoma peritonei (PMP) is a clinical syndrome with a poorly defined natural history. Relative contributions of tumor biology, patient selection, and the extent of treatment on ultimate outcome are not well characterized.

METHODS

Patients treated at the Memorial Sloan-Kettering Cancer Center between 1980 and 2002 with a diagnosis of PMP were identified. Patient characteristics, pathologic features, and details of treatment were analyzed retrospectively.

RESULTS

The 97 patients included in this study underwent a mean 2.2 +/- 0.1 operations (range, 1-6). Although complete cytoreduction was achieved in 55% (53/97), disease recurred in 91% (48/53) of patients. The median disease-free interval after complete cytoreduction was 24 months. The median overall survival was 9.8 years and was independently associated with low-grade pathologic subtype (P < 0.001) and the ability to achieve complete cytoreduction (P < 0.001). Ten-year survival was attained in 21% (20/97) of the patients, of which 90% (18/20) had low-grade pathologic features. At the time of death or completion of follow-up, only 12% (12/97) of the patients were disease free.

CONCLUSIONS

Outcome in patients with PMP is strongly associated with tumor biology. Although improved survival is associated with low-grade pathology and tumors amenable to complete cytoreduction, recurrence of PMP is common. Treatment may be beneficial, particularly in controlling symptoms, but absolute cure, defined as a prolonged disease-free state, is uncommon.

Pseudomyxoma peritonei and the urinary tract: Involvement and treatment related complications

BACKGROUND

Pseudomyxoma peritonei (PMP) is a rare clinical syndrome characterized by intraperitoneal accumulation of mucus produced by neoplastic cells of mostly appendiceal origin. The aim of this study was to analyze primary and secondary involvement and treatment-related complications of the urinary tract in PMP.

METHODS

A retrospective study of 92 patients with PMP, treated by cytoreduction and intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) at The Netherlands Cancer Institute between 1996 and 2004.

RESULTS

Seven patients presented with involvement of the urinary tract. Major urologic complications occurred in five patients, of which two had secondary involvement of the urinary tract. Major urologic complications consisted predominantly of surgical complications related to the bladder. All patients with secondary involvement and/or urologic complications had undergone previous pelvic surgery.

CONCLUSIONS

The urinary tract is rarely involved in patients with PMP. Secondary involvement is mostly observed and may be a result of seeding of PMP of pelvic origin after prior pelvic surgery. There is a low urologic complication risk of treatment with cytoreduction and HIPEC. The combination of secondary involvement and previous pelvic surgery is an omen of treatment-related urologic complications, necessitating (surgical) re-interventions and further management in close collaboration with urologists.

Pseudomyxoma peritonei: a case series and review of the literature

The purpose of this study was to use descriptive methodology to study the management of patients with pseudomyxoma peritonei (PMP) at the Princess Margaret Hospital. This is a case series of patients with a diagnosis of PMP treated between January 1, 1995 and December 31, 2001. A health record search using the morphology code for PMP was done and identified 70 patients. Additionally, an unrestricted Medline search was conducted between 1990 and 2002 for PMP. Eight cases of PMP were treated by the Gynecologic Oncology service at Princess Margaret Hospital during the study period. The patients ranged in age from 43 to 84 and presented with a pelvic mass and/or increasing abdominal girth. All but two patients underwent appendectomy as part of their surgery. Postoperative management was by gynecologic oncology for seven of eight patients. An appendiceal origin was confirmed for six patients and highly suspicious for one patient. The remaining patient underwent appendectomy, but it was not sufficiently sectioned for diagnosis. Chemotherapy was given to patients in a non-uniform fashion. Removal of mucinous tumors of the ovary should include appendectomy. Consultation from a general surgical oncologist should be sought where appendiceal origin is confirmed. Coding errors may occur in medical records at a frequency greater than is anticipated.

Lymph node metastasis in epithelial malignancies of the appendix with peritoneal dissemination does not reduce survival in patients treated by cytoreductive surgery and perioperative intraperitoneal chemotherapy

BACKGROUND

Peritoneal dissemination of appendiceal malignancy combined with regional lymph node metastasis is an unusual combination of patterns of cancer dissemination.

METHODS

A database of 501 appendiceal malignancy patients, all with documented peritoneal seeding, was used to identify 25 patients with involvement of the regional lymph nodes. All patients were uniformly treated with cytoreductive surgery plus perioperative intraperitoneal chemotherapy with mitomycin C and 5-fluorouracil. The clinical and pathologic features of the lymph node-positive patients were compared with those of the lymph node-negative patients. The effect of regional lymph node involvement on survival was determined. Within the group of lymph node-positive patients, clinical and pathologic features were tested for their effect on survival.

RESULTS

When compared with patients with no apparent lymph node positivity, patients with positive lymph nodes were more likely to have an acute abdomen as the initial presentation (P < .001). The intestinal (nonmucinous) histological type was more common (P < .001), and the disseminated peritoneal adenomucinosis histology was less common (P < .001). Survival with the aggressive treatment strategy used in these patients was not different for lymph node-positive as compared with lymph node-negative patients (P = .15 by univariate and P = .38 by multivariate analysis).

CONCLUSIONS

Appendiceal malignancy with dissemination to the lymph nodes has a more acute onset and a more frequent nonmucinous histology. With aggressive treatment strategies, lymph node-positive patients did not show a statistically significantly diminished survival.

[Pseudomyxoma peritonei: new concept and new therapeutic approach]

Pseudomyxoma peritonei is a rare disease, usually diagnosed after the discover of "jelly belly" by laparotomy. With the progress of immunohistochemistry, most authors now acknowledge the appendix to be the principal origin of this disease. Pseudomyxoma peritonei need to considered as border line malignant disease because of its inevitable persistence and progression without adapted therapeutic approach: cytoreductive surgery combined with perioperative intraperitoneal chemotherapy (intraperitoneal chemohyperthermia and/or immediate postoperative intraperitoneal chemotherapy) into specialized centres. The principal prognostic factors are the prior surgical history, the completeness of cytoreduction and especially the histopathologic grade.

Borderline ovarian tumors: diverse contemporary viewpoints on terminology and diagnostic criteria with illustrative images

The National Cancer Institute sponsored a Borderline Ovarian Tumor Workshop held in August 2003 in Bethesda, MD. This report was developed from discussions at the Workshop. The participants acknowledged several areas of disagreement on basic terminology issues and agreed that a glossary with example images would help clarify many commonly misunderstood issues. This report defines terminology used in the pathological description of borderline tumors and their variants, and illustrates examples of each of the most common entities. It also addresses controversial aspects of the definitions and issues involving specimen handling and reporting. For those issues where there is disagreement, the terminology and diagnostic approaches reflecting the differing views are presented.

Treatment of peritoneal carcinomatosis from colorectal cancer: impact of complete cytoreductive surgery and difficulties in conducting randomized trials

BACKGROUND

Colorectal peritoneal carcinomatosis (PC) is a frequent and very lethal event. However, cure may be possible with maximal cytoreductive surgery associated with early postoperative intraperitoneal chemotherapy (EPIC).

METHODS

Between 1996 and 2000, we conducted a two-center prospective randomized trial comparing EPIC plus systemic chemotherapy with systemic chemotherapy alone, both after complete cytoreductive surgery of colorectal PC. Only 35 patients could be included among the 90 who were theoretically required, mainly because of patient dissatisfaction with the inclusion criteria. For this reason, the trial was stopped prematurely.

RESULTS

Analysis of these 35 patients showed that complete resection of PC resulted in a 2-year survival rate of 60%-far above the classic 10% survival rate among patients with colorectal PC treated with systemic chemotherapy and symptomatic surgery. In this small series, EPIC did not demonstrate any advantage for survival.

CONCLUSIONS

This supports the use of complete cytoreductive surgery in selected patients and calls for a prospective randomized trial comparing adjuvant systemic chemotherapy with intraperitoneal chemohyperthermia after complete resection.

Incomplete cytoreduction in 174 patients with peritoneal carcinomatosis from appendiceal malignancy

OBJECTIVE

The aim of this study was to analyze the survival of patients with peritoneal dissemination of appendiceal malignancy having incomplete cytoreductive surgery.

SUMMARY BACKGROUND DATA

Cytoreductive surgery plus perioperative intraperitoneal chemotherapy has emerged as a new and potentially curative treatment option for patients with peritoneal dissemination of appendiceal mucinous tumors. The goal of surgery is to remove all visible disease. Nevertheless, in some patients, complete cytoreduction is not possible.

METHODS

Over a 30-year period, 645 patients with epithelial peritoneal surface malignancy of appendiceal origin were treated with cytoreductive surgery and intraperitoneal chemotherapy by a single surgeon. One hundred seventy-four (27.1%) of these patients had an incomplete cytoreduction. A critical statistical analysis of the impact of selected clinical features on survival was performed from a prospective database.

RESULTS

Mortality and morbidity rates were 0% and 33.3%, respectively. Median survival of these 174 patients was 20.5 months and their 1-year, 3-year, and 5-year survival rates were 71%, 34%, and 15%, respectively. By multivariate analysis, the presence of signet ring cells and lymph node involvement were independent prognostic indicators of poor survival (P = 0.047 and P < 0.001, respectively). Patients who underwent more than 1 cytoreduction or repeat intraperitoneal chemohyperthermia showed significant improvement in survival (P = 0.018 and P < 0.001, respectively)

CONCLUSION

Incomplete cytoreduction plus perioperative intraperitoneal chemotherapy of peritoneal dissemination from appendiceal malignancy results in limited long-term survival. Patients with signet ring histology or lymph node involvement have an especially poor outcome. Repeat cytoreduction and intraperitoneal chemohyperthermia may improve outcome.

Mucinous borderline ovarian tumors: Points of general agreement and persistent controversies regarding nomenclature, diagnostic criteria, and behavior

This report focuses on the borderline category of ovarian mucinous tumors and summarizes the points of general agreement and persistent controversies identified by experts in the field who participated in the Borderline Ovarian Tumor Workshop held in Bethesda, MD, in August 2003. Points of agreement and persistent controversies regarding nomenclature, diagnostic criteria, and behavior are addressed for the following ovarian mucinous tumor categories: mucinous borderline ovarian tumor (M-BOT; synonymously referred to as atypical proliferative mucinous tumor of ovary or mucinous ovarian tumor of low malignant potential), M-BOT with intraepithelial carcinoma, and M-BOT with microinvasion. The morphologic spectrum of M-BOTs with regard to distinction from mucinous cystadenoma and the confluent glandular/expansile type of invasive mucinous carcinoma is also addressed. Non-ovarian mucinous tumors, including the secondary ovarian mucinous tumors associated with pseudomyxoma peritonei and metastatic mucinous carcinomas with a deceptive pattern of invasion, are recognized as tumors that can simulate primary M-BOTs. Improved classification of these mucinous tumors has clarifed the behavior of true M-BOTs by excluding these simulators from the M-BOT category.

Peritonectomy and intraperitoneal hyperthermic perfusion (IPHP): a strategy that has confirmed its efficacy in patients with pseudomyxoma peritonei

BACKGROUND

Pseudomyxoma peritonei (PMP) is a rare disease with a poor prognosis characterized by a complete redistribution of mucin within the peritoneal cavity. The aim of this multicentric study was to evaluate the survival, morbidity, toxicity, and mortality of patients with PMP treated by cytoreductive surgery (CRS) with intraperitoneal hyperthermic perfusion (IPHP).

METHODS

Thirty-three patients with PMP (21 males and 12 females) were enrolled in a phase II clinical trial. One patient underwent surgery twice because of disease recurrence. CRS was performed with peritonectomy procedures. The closed abdomen technique was employed for IPHP with use of cisplatin (25 mg/m2/L) plus mitomycin-C (3.3 mg/m2/L) for 60 minutes under hyperthermic conditions (42.5 degrees C).

RESULTS

Thirty-one patients (92%) were optimally cytoreduced. Five-year overall survival, progression-free survival, and locoregional progression-free survival rates were 97%, 43%, and 59%, respectively. Grade II and grade III morbidity was observed in 5 patient (15%) and 6 patients (18%), respectively. There was one treatment-related death (3%), 21 days after treatment.

CONCLUSIONS

CRS associated with IPHP permitted complete tumor removal with an acceptable morbidity and mortality for patients with PMP. This study confirms the efficacy of the combined treatment in terms of long-term survival and local disease control.

From the archives of the AFIP: radiologic staging of ovarian carcinoma with pathologic correlation

Ovarian cancer is the deadliest gynecologic malignancy, with approximately 70% of patients having peritoneal involvement at the time of diagnosis. It spreads predominantly by direct invasion and intraperitoneal dissemination. The staging system is surgically based, with stage I disease being limited to one or both ovaries. In stage II disease, there is extraovarian spread of tumor, but it does not extend beyond the pelvis. Stages III and IV disease are considered advanced, with stage III ovarian cancer including diffuse peritoneal disease involving the upper abdomen and stage IV disease having distant metastases including hepatic lesions. Common sites of intraperitoneal seeding include the omentum, paracolic gutters, liver capsule, and diaphragm. Thickening, nodularity, and enhancement are all signs of peritoneal involvement. Although computed tomography is the most common imaging modality used to stage ovarian cancer, magnetic resonance imaging has been shown to be equally accurate. Currently, however, no imaging modality allows microscopic spread of disease to be ruled out, and a full staging laparotomy is always required. Early ovarian cancer is treated with comprehensive staging laparotomy, whereas advanced but operable disease is treated with primary cytoreductive surgery (debulking) followed by adjuvant chemotherapy. Patients with unresectable disease may benefit from neoadjuvant (preoperative) chemotherapy before debulking.

Ovarian mucinous borderline tumors of intestinal type without intraepithelial carcinoma: Are they still tumors of low malignant potential?

The purpose of this study was to clarify whether ovarian intestinal-type mucinous borderline tumors without intraepithelial carcinoma should still be considered tumors of low malignant potential. Fifty-five intestinal-type mucinous borderline tumors without intraepithelial carcinoma in which a section had been taken for each 2 cm or less of the tumor's greatest diameter were selected. The International Federation of Gynecology and Obstetrics' stage and follow-up data of each case were examined. All 55 patients had stage I disease (including one with pseudomyxoma peritonei of superficial organizing type, according to Lee and Scully's classification). No patient had metastases or died from the tumor, although in one patient who underwent cystectomy, the disease recurred in the remaining ovary 5 years after surgery. However, the patient was alive and well after undergoing salpingo-oophorectomy. The patient with pseudomyxoma peritonei had no recurrence and did not die from the tumor. These findings indicated that intestinal-type mucinous borderline tumors, in which intraepithelial carcinoma has been ruled out with adequate histological sampling, are benign tumors, not tumors of low malignant potential. It is proposed here that these tumors should be designated as high-grade mucinous adenoma. Unilateral salpingo-oophorectomy is the recommended treatment because cystectomy alone may allow local recurrence in the remaining ovary.

Clinically aggressive pseudomyxoma peritonei: a variant of a histologically indolent process

BACKGROUND

Three distinct morphologic types of pseudomyxoma peritonei syndrome have been defined: disseminated peritoneal adenomucinosis (DPAM), peritoneal mucinous carcinoma (PMCA), and a hybrid morphologic type. Prognosis is best in patients with DPAM; unfortunately, some patients with DPAM succumb to a rapidly progressive disease process.

METHODS

We identified a subset of 11 patients with a histopathology of DPAM but a clinical course showing an invasive disease process. As a comparison group, from a database of 501 patients with pseudomyxoma peritonei, we selected 22 age- and sex-matched controls with a DPAM histology who are alive with no evidence of disease. Clinical factors were identified for comparison of case and control groups. Expression of mucin antigens, mucin (MUC)1 and MUC2, were evaluated using immunohistochemistry.

RESULTS

The study group consisted of 11 patients (five men and six women), with a median survival of 52.2 months (SD 7.46) and a 31% 5-year survival. All 22 matched control cases (10 men and 12 women) are alive and disease-free. Clinical data on the study and control groups including co-morbidity were similar. No significant difference in the expression of MUC1 (P = 0.74, Fisher's exact test) or MUC2 (P = 0.34, Fisher's exact test) was demonstrated between groups.

CONCLUSIONS

Further investigation of pseudomyxoma peritonei at a molecular and genetic level may help to formulate a more comprehensive classification.

Primary epithelial neoplasms and other epithelial lesions of the appendix (excluding carcinoid tumors)

Epithelial tumors of the appendix range from low-grade mucosal-based tumors which, when confined to the appendix, have an excellent prognosis but, once outside the appendix, have a fair prognosis and often a prolonged disease course, to high grade invasive carcinomas that are rapidly fatal. Low grade mucinous neoplasms may rupture and spread to the peritoneum as pseudomyxoma peritonei, and the nomenclature of these tumors has been the subject of considerable disagreement among pathologists; the designation "low grade appendiceal mucinous neoplasm" has recently been proposed for reasons discussed herein. Demonstrating rupture of these neoplasms may require particularly diligent gross and microscopic evaluation as the rupture site often heals over leaving only subtle evidence of its presence. Invasive adenocarcinomas are often mucinous and may also spread to the peritoneum. Against this backdrop, the clinical and pathologic features of low grade appendiceal mucinous neoplasms and mucinous adenocarcinomas, as well as other types such as typical colorectal type and signet-ring cell type, are reviewed. In addition, emerging entities, serrated polyps and serrated adenomas, whose significance is only beginning to be understood, are considered. Retention cysts, hyperplastic polyps, and diffuse mucosal hyperplasia, although not necessarily neoplastic, are reviewed here as they may enter into the differential diagnosis of appendiceal mucinous neoplasms.

Peritoneal carcinomatosis from digestive tract cancer: new management by cytoreductive surgery and intraperitoneal chemohyperthermia

Peritoneal carcinomatosis is a common manifestation of digestive-tract cancer and has been regarded a terminal disease with a short median survival. Over the past decade, a new locoregional therapeutic approach combining cytoreductive surgery with intraperitoneal chemohyperthermia (IPCH) has evolved. Because of its limited benefits, high morbidity and mortality, and high cost, this comprehensive management plan requires accurate patient selection. Quantitative prognostic indicators are needed to assess a patient's eligibility for combined treatment, including tumour histopathology, classification of carcinomatosis extent, assessment of completeness of cytoreduction, and determination of the extent of previous surgery. Patients with pseudomyxoma peritonei and those with peritoneal dissemination of digestive-tract cancer have shown promising survival. Complete cytoreduction with no visible disease persisting is a requirement for long-term benefit. In Japan and Korea, use of IPCH as prophylactic treatment in potentially curative gastric-cancer resection has shown improved survival and lower peritoneal recurrence rates. IPCH combined with cytoreductive surgery seems to be an effective therapeutic approach in carefully selected patients, and offers a chance for cure or palliation in this condition with few alternative treatment options.

Right hemicolectomy does not confer a survival advantage in patients with mucinous carcinoma of the appendix and peritoneal seeding

BACKGROUND

Traditionally epithelial malignancies of the appendix with or without carcinomatosis have been treated by right hemicolectomy. Recent accumulation of a large number of patients with this disease has enabled a re-evaluation of this surgical judgement.

METHODS

Clinical data on 501 patients with epithelial malignancy of the appendix were collected prospectively. All patients had peritoneal seeding at the time of referral and were treated by cytoreductive surgery and perioperative intraperitoneal chemotherapy. The main independent variable for statistical analysis was the surgical procedure used to resect the primary cancer (appendicectomy alone versus right hemicolectomy). Nineteen other clinical and pathological variables were considered as control variables. The endpoint for all analyses was survival.

RESULTS

Median follow-up after the initial diagnosis was 4 years. The rate of regional lymph node positivity was 5.0 per cent. When the incidence of lymph node metastasis was determined by histological type, it was statistically significantly higher in intestinal (66.7 per cent) than in mucinous (4.2 per cent) tumours (P < 0.001). The presence of lymph node metastases had no influence on prognosis (P = 0.155). The surgical procedure (appendicectomy alone versus right hemicolectomy) had an influence on patient survival by univariate analysis (P < 0.001), but not by multivariate analysis (P = 0.258).

CONCLUSION

Right hemicolectomy does not confer a survival advantage in patients with mucinous appendiceal tumours with peritoneal seeding. These data suggest that right hemicolectomy should be avoided unless metastatic involvement of the appendiceal or distal ileocolic lymph nodes is documented by biopsy, or the resection margin is inadequate.

Appendiceal adenocarcinoma: long-term outcomes after surgical therapy

PURPOSE

Appendiceal adenocarcinomas are very rare. We analyzed contemporary outcomes associated with surgical therapies for these malignancies.

METHODS

Retrospective outcomes for patients treated at a tertiary academic medical center from 1981 through 2001 were analyzed.

RESULTS

A total of 36 patients (22 females (61 percent) mean age, 52 years) with appendiceal adenocarcinoma were treated. Eighty-eight percent of patients presented with symptoms of acute appendicitis. Eighteen (50 percent) patients underwent curative resection (7 primary right hemicolectomies, 10 appendectomies + subsequent right hemicolectomy, and 1 appendectomy alone). Mean length of follow-up was 55 months. Overall five-year survival rate was 46 percent. The five-year survival rate after curative resection was 61 percent and after palliative surgery was 32 percent ( P < 0.05). Among patients who underwent curative resection, factors associated with improved five-year survival rates included histologic type (79 vs. 32 percent for colonic vs. mucinous types, respectively; P < 0.05), T stage (75 vs. 47 percent for T1 and 2 vs. T3 and 4, respectively; P < 0.05), and tumor grade (100 vs. 46 percent for well-differentiated tumors vs. moderately or poorly differentiated tumors, respectively; P < 0.05).

CONCLUSIONS

Patients undergoing surgery for appendiceal adenocarcinoma can be stratified according to prognostic variables. The role of adjuvant therapies for patients with poor prognostic factors needs to be evaluated in a multi-institutional setting.

The etiology, clinical presentation, and management of pseudomyxoma peritonei

PMP is a rare condition, which, although of "borderline malignancy," is invariably fatal. Difficulties exist with the definition of PMP. It has been broadly applied to include a heterogenous group of pathologic lesions that present clinically with "jelly belly" due to mucinous ascites. The relatively few reports in the literature commonly use different pathologic definitions, and there is no consensus on the point of separation between PMP and carcinomatosis secondary to a mucinous adenocarcinoma. Sugarbaker has suggested "the term pseudomyxoma peritonei syndrome be strictly applied to a pathologically and prognostically homogenous group of cases characterized by histologically benign peritoneal tumors that are frequently associated with an appendiceal mucinous adenoma." This definition excludes all cases with mucinous adenocarcinoma. The optimal treatment is undoubtedly complete tumor excision, by complex surgical peritonectomy procedures, taking on average 10 hours. Surgery is usually combined with intraperitoneal, and now intraoperative heated chemotherapy. These techniques have a high morbidity and mortality. The rarity of the condition, together with the risks associated with definitive treatment, suggests that such treatment ought to be centralized in a few centers, covering a large population. The search continues for safer, less aggressive treatments, but is hampered by a lack of hard evidence and the absence of experimental animal or human models to evaluate emerging strategies.

Quantitative prognostic indicators of peritoneal surface malignancy: carcinomatosis, sarcomatosis, and peritoneal mesothelioma

Quantitative prognostic indicators for carcinomatosis and sarcomatosis are essential in the management of peritoneal surface malignancy. This need is greatly accentuated as a new comprehensive therapeutic approach emerges. The assessment of tumor histopathology, prior surgical score, lesion size, and distribution (Gilly classification and peritoneal cancer index) and the completeness of cytoreduction scores are the tools that are currently in use. Although current assessments have greatly facilitated clinical research, more precise comparisons demand improved quantitation and greater precision. Preoperative and intraoperative assessment of peritoneal surface malignancy will improve patient selection. Now more than ever, postoperative distribution and volume assessments using noninvasive modalities are needed for follow-up.

Appendiceal mucinous neoplasms: a clinicopathologic analysis of 107 cases

The classification of appendiceal mucinous tumors is controversial and terminology used for them inconsistent, particularly when they lack overtly malignant features but are associated with extra-appendiceal spread. We reviewed 107 appendiceal mucinous neoplasms and classified them as low-grade appendiceal mucinous neoplasm (LAMN) (n = 88), mucinous adenocarcinomas (MACAs) (n = 16), or discordant (n = 3) based on architectural and cytologic features. LAMNs were characterized by a villous or flat proliferation of mucinous epithelium with low-grade atypia. Thirty-nine tumors were confined to the appendix, but 49 had extra-appendiceal tumor spread, including 39 with peritoneal tumor characterized by mucin pools harboring low-grade mucinous epithelium, usually dissecting in a hyalinized stroma. Eight of the 16 MACAs lacked destructive invasion of the appendiceal wall and eight showed an infiltrative pattern of invasion. Extra-appendiceal tumor spread was present in 12 MACAs (four peritoneum, seven peritoneum and ovaries; one ovaries only). In MACAs with an infiltrative pattern, peritoneal tumor consisted of glands and single cells in a desmoplastic stroma. The peritoneal tumor in the remaining cases consisted of mucin pools that contained mucinous epithelium with high-grade atypia and, in some cases, increased cellularity compared with that seen in peritoneal spread in cases of LAMN. Three cases were classified as discordant because the appendiceal tumors were LAMNs but the peritoneal tumors were high-grade. Follow-up was available for 49 LAMNs, 15 MACAs, and 2 discordant cases. None of the patients with LAMNs confined to the appendix experienced recurrence (median follow-up 6 years). LAMNs with extra-appendiceal spread were associated with 3-, 5-, and 10-year survival rates of 100%, 86%, and 45%, respectively. Patients with MACA had 3- and 5-year survival rates of 90% and 44%, respectively (p = 0.04). The bulk of peritoneal disease correlated with prognosis among patients with MACA (p = 0.04) and, to a lesser degree, among patients with LAMNs (p = 0.07). We conclude that: 1) appendiceal mucinous neoplasms can be classified as either low-grade mucinous neoplasms or mucinous adenocarcinoma based on architectural and cytologic features; 2) tumors that can be confidently placed in the low-grade group (which requires rigorous pathologic evaluation of the appendix) and are confined to the appendix are clinically benign in our experience to date; 3) low-grade tumors confined to the appendix are morphologically identical to those with extra-appendiceal spread (except for the usual identification of breach of the wall in the latter cases) and the same designation is appropriate for the appendiceal neoplasia in each situation; 4) the long-term outlook for patients with low-grade tumors and peritoneal spread is guarded with just over half dying of disease after 10 years; 5) appendiceal mucinous tumors with destructive invasion of the appendiceal wall, complex epithelial proliferations, or high-grade nuclear atypia generally pursue an aggressive clinical course and should be classified as mucinous adenocarcinomas; 6) peritoneal tumor can be classified as involvement by LAMN or MACA, and this distinction is of prognostic significance; 7) bulky peritoneal tumor worsens prognosis; and 8) LAMNs associated with high-grade peritoneal tumor behave as adenocarcinoma.

Pathology of ovarian carcinoma

Serous carcinoma is the most common type of ovarian cancer and usually is associated with peritoneal metastases and poor survival except for meticulously staged patients with tumors confined to the ovaries. Endometrioid and clear cell carcinomas account for most nonserous carcinomas and more often present with low-stage disease; survival for the various cell types is similar when stratified by stage. Borderline ovarian tumors can be subdivided into benign and malignant neoplasms, and in the view of some experts, this renders the borderline category obsolete. Women with typical serous borderline tumors (atypical proliferative serous tumors) constitute most of these patients and have virtually 100% survival, unless invasive peritoneal implants are present. Micropapillary serous carcinomas (a less common variant, also called serous borderline tumor with a micropapillary pattern) and tumors with invasive implants behave similar to low-grade invasive carcinomas.

Pseudomyxoma peritonei: the 'controversial' disease

Pseudomyxoma peritonei (PMP) is a rare disease that is characterized by a large amount of mucinous ascites with peritoneal and omental implants. The etiology of the disease remains unclear. Histologically, two main categories have been described: disseminated peritoneal adenomucinosis (DPAM) and peritoneal mucinous carcinomatosis (PMCA). It is commonly diagnosed incidentally at laparotomy. Most investigators agree that radical surgical debulking and appendectomy are the cornerstone of treatment, but the optimal management of the disease remains controversial. The role of intraoperative and intraperitoneal chemotherapy has been evaluated by a number of authors. The clinical outcomes vary widely between the benign and the malignant forms and between the different treatment modalities. We discuss the pathology, origin, clinical presentation, diagnosis, treatment, and prognosis of PMP.

Primary and metastatic mucinous adenocarcinomas in the ovaries: incidence in routine practice with a new approach to improve intraoperative diagnosis

Mucinous carcinomas are reported to comprise 6-25% of ovarian carcinomas (mean 12%), but recent refinements in the interpretation of histologic features of noninvasive and metastatic mucinous carcinomas suggest that this may be an overestimate. Mucinous carcinomas in the ovaries are commonly metastatic, but the proportion of primary versus metastatic mucinous carcinomas in unselected patients is unknown. To evaluate the histologic-type distribution of ovarian surface epithelial carcinomas, a consecutive series of 124 ovarian carcinomas was reviewed using uniform current criteria. Microinvasive and intraepithelial carcinomas and carcinomas arising in germ cell and stromal tumors were excluded. To evaluate the proportions of primary and metastatic tumors among the mucinous carcinomas, 52 consecutive mucinous carcinomas from nonreferral patients were reviewed. Three of 124 primary ovarian carcinomas were pure mucinous carcinomas (2.4%). Among 52 cases of mucinous carcinomas in the ovaries, 40 (77%) were metastatic and 12 (23%) were primary. Among the 12 primary mucinous tumors, three were atypical proliferative mucinous tumors with microinvasion and nine were invasive mucinous carcinomas. Among the 40 metastatic mucinous tumors, 18 (45%) were from the gastrointestinal tract, 8 (20%) were pancreatic, 7 (18%) were gynecologic malignancies (5 cervical, 2 endometrial), 3 (8%) were from the breast, and 4 (10%) were of unknown primary site. A simple rule that classifies all bilateral mucinous carcinomas as metastatic, unilateral mucinous carcinomas <10 cm as metastatic, and unilateral mucinous carcinomas >or=10 cm as primary correctly classified 90% of the neoplasms. This algorithm for distinguishing primary and metastatic mucinous carcinomas in the ovary can be used at the time of intraoperative consultation to guide surgical management. After careful exclusion of noninvasive, microinvasive, and metastatic tumors, pure mucinous adenocarcinoma primary in the ovary appears to be substantially less common than previously reported.

Third look surgery and beyond for appendiceal malignancy with peritoneal dissemination

BACKGROUND AND OBJECTIVES

Second look surgery has been previously studied in patients with recurrent peritoneal dissemination from appendiceal malignancy. However, selection criteria for third, fourth, and subsequent reoperations are not available.

METHODS

Five hundred and one patients with epithelial peritoneal surface malignancy of appendiceal origin underwent treatment with cytoreductive surgery and intraperitoneal chemotherapy during an 18-year period. Forty-five of these patients (8.9%) underwent three or more operative interventions. A critical statistical analysis of the impact of selected clinical features on survival was performed from a prospective database.

RESULTS

Overall 5-year survival of these 45 patients was 70%. Five- and ten-year survival rates for patients with three interventions were 60 and 48%, for four interventions were 78 and 36%, and for five or more interventions were 100 and 80%. Sites of recurrent disease, histopathologic type of tumor, and lymph node status had no impact on survival. A complete second and third cytoreduction was associated with an improved 5-year survival rate.

CONCLUSIONS

Prolonged survival in patients with three or more reoperations was significantly associated with a complete cytoreduction. However, after four or more interventions, the effects of tumor biology may predominate. Although 5-year survival is likely with multiple reoperations, prolonged follow-up shows that cancer cure is a rare event.

Mucinous tumors arising in ovarian mature cystic teratomas: relationship to the clinical syndrome of pseudomyxoma peritonei

Recent studies have redefined pseudomyxoma peritonei (PMP) as a specific clinicopathologic syndrome in which mucinous ascites is accompanied by peritoneal lesions characterized by bland to low-grade adenomatous mucinous epithelium intimately associated with pools of extracellular mucin and fibrosis, diagnosed pathologically as disseminated peritoneal adenomucinosis (DPAM). Most recent studies support an appendiceal rather than ovarian origin for virtually all cases of PMP/DPAM in women. Peritoneal mucinous tumors with the histologic features of carcinoma (peritoneal mucinous carcinomatosis, PMCA) are also rarely ovarian in origin and are distinguished from DPAM, even though they may produce abundant mucin, because PMCA and DPAM are pathologically and prognostically distinct. We report three cases of PMP (mucinous ascites) associated with ruptured mucinous tumors arising in ovarian mature cystic teratomas. Two tumors contained bland to low-grade adenomatous mucinous epithelium associated with dissecting mucin, identical to the mucinous tumors that secondarily involve the ovaries and peritoneum in PMP/DPAM derived from ruptured appendiceal mucinous adenomas. The third was composed of both low-grade adenomatous tumor and areas of mucinous carcinoma. In all cases the appendices were microscopically normal. The mucinous ascites associated with the low-grade tumors contained only a few fragments of detached bland mucinous epithelium in one and none in the other. The mucinous ascites associated with the higher-grade tumor contained one fragment of atypical mucinous epithelium. All three mucinous tumors were cytokeratin 20-positive and cytokeratin 7-negative, consistent with a lower gastrointestinal tract-type rather than primary ovarian-type mucinous tumor immunophenotype. Mucinous tumors arising in ovarian mature cystic teratomas are morphologically and immunohistochemically consistent with gastrointestinal tract-type mucinous tumors, which likely arise from gut elements of the teratoma. Rupture can on rare occasions produce mucinous ascites containing very scant mucinous epithelium, but additional follow-up will be required to determine whether these ovarian tumors ever lead to recurrent disease accompanied by the characteristic peritoneal lesions of DPAM or PMCA. Such tumors probably represent the only cases of ovarian origin of PMP.

Pseudomyxoma peritonei

Pseudomyxoma peritonei is a rare form of mucinous ascites associated with peritoneal and omental implants. The origin is controversial, and recent immunohistochemical and molecular genetic evidence suggests the appendix to be the likely site. The condition often presents as an incidental finding at laparotomy. Ultrasonography, computed tomography and magnetic resonance imaging aid in preoperative diagnosis. Treatment remains controversial, surgery being the main stay. The role of intraperitoneal and systemic chemotherapy is poorly defined. We review the literature on the pathology, clinical features and treatment options in pseudomyxoma peritonei.

Diagnostic criteria and behavior of ovarian seromucinous (endocervical-type mucinous and mixed cell-type) tumors: atypical proliferative (borderline) tumors, intraepithelial, microinvasive, and invasive carcinomas

Ovarian endocervical-type (müllerian) mucinous tumors and tumors composed of a mixture of endocervical-type mucinous, serous, endometrioid, squamous, and indifferent cells with abundant eosinophilic cytoplasm reported to date have been primarily limited to borderline and microinvasive types, with only one report of a disease-related death. The clinicopathologic features of 54 endocervical-type and mixed cell-type mucinous tumors, defined as tumors with papillary architecture resembling serous tumors but containing endocervical-type mucinous epithelium, were evaluated. Thirty-four tumors (64%) were classified as atypical proliferative (borderline) tumors based on the absence of stromal invasion and the absence of micropapillary architecture measuring >5 mm. Five tumors (9%) qualified as intraepithelial carcinoma based on the presence of marked cytologic atypia or a complex cribriform growth pattern involving the epithelium covering the surface of papillae or lining cystic spaces. Eight tumors (15%) with stromal invasion < or =5 mm were classified as microinvasive carcinoma. Seven tumors (13%) with either stromal invasion (five tumors) or micropapillary architecture measuring >5 mm (two tumors) were classified as carcinoma. Sixteen tumors (30%) were bilateral, and endosalpingiosis was identified in 41% of cases. Serous-type differentiation was present in all cases. Of the 29 patients with atypical proliferative tumors, intraepithelial carcinomas, and microinvasive carcinomas for whom follow-up was available, there were no disease-related deaths. In contrast, of the seven patients whose tumors had either stromal invasion or micropapillary architecture >5 mm, two stage III patients died of disease (one with frank invasion and one with a micropapillary tumor that lacked stromal invasion). One other stage III patient with a noninvasive micropapillary carcinoma was alive with disease at 84 months. The remaining four patients (three stage I and one stage III) were alive with no evidence of disease. In summary, most endocervical-type atypical proliferative tumors are stage I and benign. The presence of either intraepithelial carcinoma or microinvasion has no adverse effect on behavior. Rare endocervical-type mucinous tumors demonstrate histologically malignant features and aggressive behavior that warrant designation as carcinoma. As with serous tumors, micropapillary architecture without frank invasion in endocervical-type mucinous tumors is associated with disease recurrence and death when presenting as advanced-stage disease. All the tumors in this study were composed of a heterogeneous population of cells, consisting mainly of serous (ciliated) and endocervical-type mucinous cells. In addition, they all contained endometrioid-type cells, hobnail cells, and indifferent cells with abundant eosinophilic cytoplasm to a varying degree. Accordingly, it appears that tumors that feature endocervical-type mucinous cells are rarely if ever pure but almost invariably of mixed cell type. Despite containing mucinous epithelium, the papillary architecture, serous-type differentiation, association with endosalpingiosis, frequent bilaterality, size, and clinical behavior of endocervical-type mucinous tumors closely resemble serous tumors. We therefore recommend the term "seromucinous" for these tumors, which acknowledges both their serous and mucinous features.