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

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.

Survival Time in Treatment Modalities of Gastric Carcinoma at King Khalid Hospital- Jeddah Saudi Arabia: a Retrospective Cohort Study

Background:

Gastric cancer (GC) is the fifth most common cancer worldwide and is responsible for 10% of annual cancer deaths. Gastric cancer treatment requires a multimodality approach involving surgery, adjuvant chemotherapy (AC), and neoadjuvant chemotherapy (NAC) for locally advanced tumors. Surgical removal of the tumor is the most common and effective curative approach with a more promising survival rate.

Objectives:

Due to the scarcity of studies in the kingdom of Saudi Arabia, this study aims to provide an epidemiological background on the subject and compare multiple treatments and their survival outcomes in a tertiary hospital in the western region.

Methods:

After obtaining the IB approval, data was collected from medical files of all histologically confirmed GC patients (101) between the years 2000-2015. In this study, patients’ demographics, tumor characteristics, treatment types, and patients’ vital status (deceased or alive) were collected. Survival analysis between treatment modalities subgroups was carried out using the Kaplan-Meier test and Cox regression model.

Results:

Out of 101 patients with GC, 65.35% were males with a mean age of 64.9±19 years and 61.71±17.83 years for female patients. Most patients had a stage IV tumor 47 (74.6%). The adjuvant chemotherapy group had a median survival time of 140 months (95% CI 33.72-246.29), while the neoadjuvant chemotherapy was 69 months. Patients who only underwent surgery had a median survival time of 28 months (95% CI 0-56.14), whereas patients who received no intervention had a median survival time of 8 months (95% CI 1.47-14.53) (log-rank = 0.002). The median overall survival time for all patients was 28 months (95%CI 0-77.68) with an overall five-year survival rate of 19.6%. Cox regression model revealed that treatment type and tumor stage were significant predictors of survival with p values of 0.001 and 0.009, respectively.

Conclusion:

Adjuvant, neoadjuvant, and palliative chemotherapy constitute the paramount treatment modalities of GC with adjuvant treatment having the highest survival time. However, these modalities necessitate further understanding as to whether other factors play a role in the selection of one treatment with the preferable outcome.

The use of intraperitoneal chemotherapy for gastric malignancies

Introduction: Gastric cancer is the fourth/fifth most common malignancy worldwide, with only a quarter of patients achieving a 5-year survival rate. It has been estimated that 15-50% or more of patients have peritoneal disease upon surgical exploration. Until the early 1990s, peritoneal metastasis was considered as terminal stage of the disease; in the late 1990s, selected patients with peritoneal metastasis were recategorized as local disease. Over the past two decades, the treatment of peritoneal involvement has transformed, and cytoreductive surgery plus intraperitoneal therapy have drastically altered the natural course of several malignancies. Areas covered: We performed a review of studies available on PubMed from 1 January 2014 to 31 July 2019 and the analysis of their reference citations. We describe the most current intraperitoneal chemotherapy opportunities in the treatment of gastric cancer: hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC), laparoscopic hyperthermic intraperitoneal chemotherapy (LHIPEC), neoadjuvant intraperitoneal and systemic chemotherapy (NIPS), LHIPEC + NIPS, extensive intraoperative peritoneal lavage (EIPL), early postoperative intraperitoneal chemotherapy (EPIC), and pressurized intraperitoneal aerosol chemotherapy (PIPAC). Expert opinion: Comprehensive treatment consisting of CRS combined with perioperative intraperitoneal/systemic chemotherapy can, today, be considered an effective strategy to improve the long-term survival of gastric cancer patients with peritoneal metastasis.

Role of radiation therapy for retroperitoneal sarcomas: An eight-institution study from the US Sarcoma Collaborative

BACKGROUND

The use of radiation therapy in the treatment of retroperitoneal sarcomas has increased in recent years. Its impact on survival and recurrence is unclear.

METHODS

A retrospective propensity score matched (PSM) analysis of patients with primary retroperitoneal soft tissue sarcomas, who underwent resection from 2000 to 2016 at eight institutions of the US Sarcoma Collaborative, was performed. Patients with metastatic disease, desmoid tumors, and palliative resections were excluded.

RESULTS

Total 425 patients were included, 56 in the neoadjuvant radiation group (neo-RT), 75 in the adjuvant radiation group (adj-RT), and 294 in the no radiotherapy group (no-RT). Median age was 59.5 years, 186 (43.8%) were male with a median follow up of 31.4 months. R0 and R1 resection was achieved in 253 (61.1%) and 143 (34.5%), respectively. Overall 1:1 match of 46 adj-RT and 59 neo-RT patients was performed using histology, sex, age, race, functional status, tumor size, grade, resection status, and chemotherapy. Unadjusted recurrence-free survival (RFS) was 35.9 months (no-RT) vs 33.5 months (neo-RT) and 27.2 months (adj-RT), P = .43 and P = .84, respectively. In the PSM, RFS was 17.6 months (no-RT) vs 33.9 months (neo-RT), P = .28 and 19 months (no-RT) vs 27.2 months (adj-RT), P = .1.

CONCLUSIONS

Use of radiotherapy, both in adjuvent or neoadjuvent setting, was not associated with improved survival or reduced recurrence rate.

Exosomal miR-181b-5p Downregulation in Ascites Serves as a Potential Diagnostic Biomarker for Gastric Cancer-associated Malignant Ascites

Purpose

Peritoneal carcinomatosis in gastric cancer (GC) patients results in extremely poor prognosis. Malignant ascites samples are the most appropriate biological material to use to evaluate biomarkers for peritoneal carcinomatosis. This study identified exosomal MicroRNAs (miRNAs) differently expressed between benign liver cirrhosis-associated ascites (LC-ascites) and malignant gastric cancer-associated ascites (GC-ascites), and validated their role as diagnostic biomarkers for GC-ascites.

Materials and Methods

Total RNA was extracted from exosomes isolated from 165 ascites samples (73 LC-ascites and 92 GC-ascites). Initially, microarrays were used to screen the expression levels of 2,006 miRNAs in the discovery cohort (n=22). Subsequently, quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR) analyses were performed to validate the expression levels of selected exosomal miRNAs in the training (n=70) and validation (n=73) cohorts. Furthermore, carcinoembryonic antigen (CEA) levels were determined in ascites samples.

Results

The miR-574-3p, miR-181b-5p, miR-4481, and miR-181d were significantly downregulated in the GC-ascites samples compared to the LC-ascites samples, and miR-181b-5p showed the best diagnostic performance for GC-ascites (area under the curve [AUC]=0.798 and 0.846 for the training and validation cohorts, respectively). The diagnostic performance of CEA for GC-ascites was improved by the combined analysis of miR-181b-5p and CEA (AUC=0.981 and 0.946 for the training and validation cohorts, respectively).

Conclusions

We identified exosomal miRNAs capable of distinguishing between non-malignant and GC-ascites, showing that the combined use of miR-181b-5p and CEA could improve diagnosis.

Identification of a 3-mRNA signature as a novel potential prognostic biomarker in patients with ovarian serous cystadenocarcinoma in G2 and G3

The use of mRNAs as biomarkers serves to diagnose, treat, as well as aid the prognosis of cancer. The present study involved an analysis of mRNAs in the cell cycle at the G2 and G3 tumor grades for the prognosis of ovarian serous cystadenocarcinoma (OSC) using 364 clinical samples (G2:G3=42:322). Statistics aided the identification of NPFFR2, XPNPEP2 and CELA3B; the 3-mRNA model that allows for classification of patients into high- and low-risk groups using a median value of 0.9580745. The rates of survival varied (P=0.00149) and the independent detection of stratification of the risk of this disease was validated with success using the 3-mRNA signature, which was demonstrated to be more successful than the weight model. This approach was revealed to provide the prognosis of grade G2 and G3 in patients with OSC compared with factors used traditionally. Compared with traditional factors, this 3-mRNA model was demonstrated to be the only and independent prognostic factor for patients with G2 and G3 stage OSC. A literature survey was also performed in the present study in order to assess the role of the 3 genes and indirectly prove their effectiveness. The establishment of this new genetic model will enhance prospective prognosis and treatment for patients with OSC.

Role of right hemicolectomy in patients with low-grade appendiceal mucinous adenocarcinoma

BACKGROUND

There is little consensus with regards to the most appropriate surgical management for low-grade appendiceal mucinous adenocarcinomas (LAMA), though right hemicolectomy is usually recommended.

METHODS

The SEER database was queried for all patients with non-metastatic LAMA. Disease specific and overall survival was compared by surgery type: 1) appendectomy, 2) formal right hemicolectomy 3) non-formal colectomy (including ileocecectomy).

RESULTS

A total of 579 patients with non-metastatic LAMA were identified. 133 (23%), 404 (70%), and 42 (7%) of patients had stage I, II, and III disease, respectively. 99 (17.1%) had appendectomy, 87 (15%) had non-formal colectomy, and 302 (52.2%) had formal right hemicolectomy. We observed no significant differences in disease specific or overall survival by surgery type. Controlling for age and stage, surgery type was not a significant predictor of disease specific or overall survival.

CONCLUSION

In patients with localized LAMA, right hemicolectomy did not increase disease specific or overall survival. Right hemicolectomy should be reserved for LAMA patients with positive margins post appendectomy.

Systemic chemotherapy and survival in patients with metastatic low-grade appendiceal mucinous adenocarcinoma

BACKGROUND

Appendiceal cancer is a rare malignancy that exhibits a wide range of histology and treatment response. Given the rarity and heterogeneous nature of the disease, it has been difficult to define optimal treatment strategies. Our goal is to examine the association between use of systemic chemotherapy and survival in patients with metastatic low-grade mucinous appendiceal adenocarcinoma.

METHODS

The National Cancer Database (2004-2015) was queried, and patients with mucinous, grade 1, stage IV appendiceal adenocarcinoma were identified. The Kaplan-Meier method was used to calculate survival, and a Cox regression model was used to identify predictors of survival.

RESULTS

Six hundred and thirty-nine patients were identified. Five-year overall survival (OS) for patients undergoing no chemotherapy vs chemotherapy was 52.9% and 61.3%, respectively. After adjusting with Cox proportional hazards model, chemotherapy was not associated with OS (HR:1.1, 95% CI:0.82-1.40, P = 0.61). Patients who underwent surgical resection (HR:0.40, 95% CI:0.28-0.57, P < .001) or were female (HR:0.61, 95% CI:0.5-0.8, P < .001) had improved survival in adjusted analysis.

CONCLUSIONS

There is no association between undergoing chemotherapy and OS in this cohort of patients with stage IV low-grade mucinous appendiceal adenocarcinoma. Development of national treatment guidelines is urgently needed for more consistency in the management of patients with appendiceal cancers.

An assessment of the survival impact of multimodal anesthesia/analgesia technique in adults undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: a propensity score matched analysis

BACKGROUND

Studies suggest volatile anesthetics and opioids may enhance the malignant potential of cancer cells. The objective of this single institution retrospective study was to evaluate the survival impact of a multimodal opioid-sparing nonvolatile anesthetic technique (MA) in a group of patients who had undergone cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for appendiceal carcinomatosis.

METHODS

Propensity score matching (PSM) and Cox proportional hazard models were used to compare the survivals of patients who received MA (MA group), to those who received volatile-opioid anesthesia (volatile-opioid group).

RESULTS

Of the 373 patients, 110 (29%) were in the MA group and 263 (71%) in the volatile-opioid group. The MA group was older (mean ± standard deviation (SD): 55 ± 11 versus 53 ± 10 years, p = .035) and had more patients with ASA scores 3 or 4 (90% versus 81%, p = .032), and those with high grade tumors (18% versus 12%, p = .009). Intraoperative opioid consumption was lower in the MA group (mean morphine equivalents ± SD: 13 ± 10 versus 194 ± 789, p < .0001). After PSM, 107 patients remained in each group. In the adjusted Cox proportional hazards model after PSM, MA was not associated with improved progression free survival (PFS) (HR 1.45, 95% CI [0.94-2.22], p = .093) or overall survival (OS) (HR 1.66, 95% CI [0.86-3.20], p = .128), when compared to volatile-opioid anesthesia.

CONCLUSIONS

In this retrospective study, a multimodal opioid-sparing nonvolatile anesthetic approach was not associated with improved survival. Precis' statement: In this study of patients undergoing major cancer surgery, the use of multimodal anesthetic and analgesic agents, while avoiding volatile anesthetics and minimizing opioid use was not associated with improved survival.

Genomic Landscape of Appendiceal Neoplasms

Purpose

Appendiceal neoplasms are heterogeneous and are often treated with chemotherapy similarly to colorectal cancer (CRC). Genomic profiling was performed on 703 appendiceal cancer specimens to compare the mutation profiles of appendiceal subtypes to CRC and other cancers, with the ultimate aim to identify potential biomarkers and novel therapeutic targets.

Methods

Tumor specimens were submitted to a Clinical Laboratory Improvement Amendments-certified laboratory (Foundation Medicine, Cambridge, MA) for hybrid-capture-based sequencing of 3,769 exons from 315 cancer-related genes and 47 introns of 28 genes commonly rearranged in cancer. Interactions between genotype, histologic subtype, treatment, and overall survival (OS) were analyzed in a clinically annotated subset of 76 cases.

Results

There were five major histopathologic subtypes: mucinous adenocarcinomas (46%), adenocarcinomas (30%), goblet cell carcinoids (12%), pseudomyxoma peritonei (7.7%), and signet ring cell carcinomas (5.2%). KRAS (35% to 81%) and GNAS (8% to 72%) were the most frequent alterations in epithelial cancers; APC and TP53 mutations were significantly less frequent in appendiceal cancers relative to CRC. Low-grade and high-grade tumors were enriched for GNAS and TP53 mutations, respectively (both χ² P < .001). GNAS and TP53 were mutually exclusive (Bonferroni corrected P < .001). Tumor grade and TP53 mutation status independently predicted OS. The mutation status of GNAS and TP53 strongly predicted OS (median, 37.1 months for TP53 mutant v 75.8 GNAS-TP53 wild type v 115.5 GNAS mutant; log-rank P = .0031) and performed as well as grade in risk stratifying patients.

Conclusion

Epithelial appendiceal cancers and goblet cell carcinoids show differences in KRAS and GNAS mutation frequencies and have mutation profiles distinct from CRC. This study highlights the benefit of performing molecular profiling on rare tumors to identify prognostic and predictive biomarkers and new therapeutic targets.

Stratification of outcomes for mucinous appendiceal adenocarcinoma with peritoneal metastasis by histological grade

AIM

To investigate the importance of a three-tiered histologic grade on outcomes for patients with mucinous appendiceal adenocarcinoma (MAA).

METHODS

Two hundred and sixty-five patients with MAA undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy were identified from a prospective database from 2004 through 2014. All pathology was reviewed by our gastrointestinal subspecialty pathologists and histological grade was classified as well-differentiated, moderately differentiated, and poorly differentiated. Survival analysis was performed using Cox proportional hazards regression.

RESULTS

There were 201 (75.8%) well-, 45 (16.9%) moderately- and 19 (7.2%) poorly-differentiated tumors. Histological grade significantly stratified the 5-year overall survival (OS), 94%, 71% and 30% respectively (P < 0.001) as well as the 5-year disease-free survival (DFS) 66%, 21% and 0%, respectively (P < 0.001). Independent predictors of DFS included tumor grade (HR = 1.78, 95%CI: 1.21-2.63, P = 0.008), lymph node involvement (HR = 0.33, 95%CI: 0.11-0.98, P < 0.02), previous surgical score (HR = 1.31, 95%CI: 1.1-1.65, P = 0.03) and peritoneal carcinomatosis index (PCI) (HR = 1.05, 95%CI: 1.02-1.08, P = 0.002). Independent predictors of OS include tumor grade (HR = 2.79, 95%CI: 1.26-6.21, P = 0.01), PCI (HR = 1.10, 95%CI: 1.03-1.16, P = 0.002), and complete cytoreduction (HR = 0.32, 95%CI: 0.11-0.92, P = 0.03). Tumor grade and PCI were the only independent predictors of both DFS and OS. Furthermore, histological grade and lymphovascular invasion stratified the risk of lymph node metastasis into a low (6%) and high (40%) risk groups.

CONCLUSION

Our data demonstrates that moderately differentiated MAA have a clinical behavior and outcome that is distinct from well- and poorly-differentiated MAA. The three-tier grade classification provides improved prognostic stratification and should be incorporated into patient selection and treatment algorithms.