Hyperthermic intraperitoneal chemotherapy in patients with incomplete cytoreduction for appendiceal pseudomyxoma peritonei: a 10-year treatment experience in China

BACKGROUND

To explore the application value of hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with incomplete cytoreduction for appendiceal pseudomyxoma peritonei (PMP).

METHODS

We retrospectively analyzed the clinical data of 526 patients with incomplete cytoreduction for appendiceal PMP to discover its prognostic factors, and the therapeutic value of HIPEC.

RESULTS

The 5-year and 10-year overall survival rates of patients after cytoreductive surgery (CRS) treated with HIPEC were significantly higher than those without HIPEC (5y-OS: 58% vs. 48%, 10y-OS: 37% vs. 16%, P = 0.032). The median progression-free survival (PFS) following CRS was 20 months, with a 20% 3-year PFS. The median PFS following CRS + HIPEC was 33 months, with a 60% 3-year PFS (P = 0.000). Univariate analysis indicated that HIPEC, gender, completeness of cytoreduction (CCR) and pathological grade had statistical difference. Multivariate analysis showed that CRS without HIPEC and high pathological grade were independent risk factors for poor prognosis and rapid tumor progression.

CONCLUSIONS

HIPEC may prolong the survival in patients with incomplete cytoreduction for low-grade appendiceal PMP. High pathological grade indicates poor survival and rapid tumor progression.

[Current treatment recommendations for pseudomyxoma peritonei]

BACKGROUND

The term pseudomyxoma peritonei (PMP) describes a clinical syndrome characterized by the presence of gelatinous intraperitoneal accumulation of mucus. It mostly originates from a mucocele of the vermiform appendix. Affected patients are often asymptomatic for a long time. Because of its indolent nature it is usually diagnosed at an advanced stage. Clinical presentation is determined by the dissemination of the tumor.

METHOD

A search and analysis of the current literature were carried out.

RESULTS

Based on the morphological characteristics PMP subtypes with various malignant potential can be differentiated. The prognosis depends on the histopathological differentiation and the clinical stage. The treatment spectrum varies from laparoscopic appendectomy to complete cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC).

CONCLUSION

Due to the rarity of PMP there are no prospective randomized studies. Therefore, there is still controversy regarding the best stage-dependent treatment strategy. This review article attempts to clarify the optimal management of mucinous neoplasms of the appendix and PMP taking the clinical presentation and the histological differentiation into consideration.

Progression of perforated cystadenoma of the appendix to pseudomyxoma peritonei over 18 years. A case report

INTRODUCTION AND IMPORTANCE

In the past, mucinous appendiceal neoplasms (MAN) greater than 2 cm in diameter were treated by a right colon resection. New data shows that treatment options are to be determined by the histopathologic grade of the appendiceal tumor and the condition of the wall of the appendix (intact vs. breached).

CASE PRESENTATION

A 39-year-old woman had an incidental diagnosis of a low-grade appendiceal mucinous neoplasm (LAMN) at the time of a hysterectomy. The appendiceal tumor had small quantities of mucus surrounding an enlarged appendix. No tumor cells were seen in the mucus by histologic study. The patient was placed in follow-up. Eighteen years later she required treatment for advanced pseudomyxoma peritonei.

CLINICAL DISCUSSION

When 5 different histopathologic types of MAN are considered with an intact vs. perforated wall of the appendix, four different treatment options develop. With LAMN and well or moderately differentiated mucinous appendiceal adenocarcinoma (MACA), the patient does not require operative intervention if the wall of the appendix is intact. If mucus or mucus plus tumor cells are identified outside the appendix an intervention is indicated. In patients, as the one presented, in whom only small amounts of mucus are outside the appendix, surveillance may be recommended.

CONCLUSIONS

In patients with a diagnosed low-grade MAN, dissemination to regional lymph nodes is rare. Dissemination to the peritoneal space places the patient at risk to develop pseudomyxoma peritonei. As this case report illustrates, if surveillance is recommended, long-term follow-up is required.

Clinical Significance of Lymph Node Dissection and Lymph Node Metastasis in Primary Appendiceal Tumor Patients After Curative Resection: a Retrospective Multicenter Cohort Study

PURPOSE

Due to its rarity and biological heterogeneity, guidelines for primary appendiceal tumor (PAT) are based on scarce evidence, resulting in no strong recommendations. The present study explored prognosis-related factors, including the timing of lymph node dissection (LND), in PAT patients after curative resection (CR) to determine the optimal surgical therapies.

METHODS

We retrospectively collected and analyzed data from 404 patients with PATs who underwent CR at 43 tertiary hospitals from 2000 to 2017. This manuscript is based on revised manuscript during review process. Please, change the bold characters to normal characters in the manuscript.

RESULTS

After propensity score matching, there were no marked differences in the recurrence-free survival (RFS) or overall survival (OS) between the primary and secondary LND groups (P = 0.993 and 0.728). A multivariate analysis showed that lymph node metastasis (LNM) was an independent factor for the RFS (hazard ratio [HR] 2.59; 95% confidence interval [CI] 1.09-6.13; P = 0.031) and OS (HR 4.70; 95% CI 1.40-15.76; P = 0.012). There were significant associations between the LNM rates and tumor depth (P < 0.0001) and the histological type (P = 0.006). There was no LNM in patients with low-grade appendiceal mucinous neoplasm (LAMN) or well-differentiated mucinous adenocarcinoma (G1) or patients with any Tis or T1 PATs.

CONCLUSIONS

LNM was an independent prognostic predictor in PATs after CR with LND. Tumor depth and histological type were not prognostic predictors but were LNM predictors. Secondary LND based on the pathological findings of resected specimens is considered an acceptable surgical management without a worse prognosis than primary LND, and it may be omitted in LAMN+G1 or in any Tis and T1 PATs.

A Predictive Model for Nodal Metastases in Patients With Appendiceal Cancers

BACKGROUND

Histologic subtypes of appendiceal cancer vary in their propensity for metastases to regional lymph nodes (LN). A predictive model would help direct subsequent surgical therapy.

METHODS

The National Cancer Database was queried for patients with appendiceal cancer undergoing surgery between 1998 and 2012. Multivariable logistic regression was used to develop a predictive model of LN metastases which was internally validated using Brier score and Area under the Curve (AUC).

RESULTS

A total of 21,647 patients were identified, of whom 9079 (41.9%) had node negative disease, 4575 (21.1%) node positive disease, and 7993 (36.9%) unknown LN status. The strongest predictors of LN positivity were histology (carcinoid tumors OR 12.78, 95% CI 9.01-18.12), increasing T Stage (T3 OR 3.36, 95% CI 2.52-4.50, T4 OR 6.30, 95% CI 4.71-8.42), and tumor grade (G3 OR 5.55, 95% CI 4.78-6.45, G4 OR 5.98, 95% CI 4.30-8.31). The coefficients from the regression analysis were used to construct a calculator that generated predicted probabilities of LN metastases given certain inputs. Internal validation of the overall model showed an AUC of 0.75 (95% CI 0.74-0.76) and Brier score of 0.188. Histology-specific predictive models were also constructed with an AUC that varied from 0.669 for signet cell to 0.75 for goblet cell tumors.

CONCLUSIONS

The risk for nodal metastases in patients with appendiceal cancers can be quantified with reasonable accuracy using a predictive model incorporating patient age, sex, tumor histology, T-stage, and grade. This can help inform clinical decision making regarding the need for a right hemicolectomy following appendectomy.

Hemicolectomy Does Not Provide Survival Benefit for Right-Sided Mucinous Colon Adenocarcinoma

BACKGROUND

The extent of bowel resection is widely debated in colon cancer surgery. Right hemicolectomy (RHC) and partial colectomy (PC) are the most common operation options for right-sided colon cancer (RCC). However, there are still no treatment guidelines or published studies to guide surgical options for mucinous adenocarcinoma (MAC) of RCC.

METHODS

Patients with MAC and non-specific adenocarcinoma (AC) of RCC who underwent RHC and PC from 2010 to 2015 in the Surveillance, Epidemiology, and End Results (SEER) database were retrieved. The general characteristics and survival were compared and analyzed.

RESULTS

A total of 27,910 RCC patients were enrolled in this study, among them 3,413 were MAC. The results showed that race, carcinoembryonic antigen (CEA) level, perineural invasion (PNI), tumor size, tumor location, TNM stage, liver metastasis, chemotherapy were significantly different between MAC and AC groups. The MAC group had similar dissected lymph nodes, but more positive lymph nodes than the AC group. The overall survival (OS) of the MAC group was poorer than that of the AC group, but cancer-specific survival (CSS) was similar between the two groups. The RHC subgroup of the MAC group had more patients of age ≤60 years, larger tumor size, cecum/ascending colon location and dissected lymph nodes than the PC subgroup, but similar positive lymph nodes, perioperative mortality, OS and CSS as the PC subgroup. Moreover, the univariate and multivariable analyses for the survival of RCC patients with MAC showed that RHC might not be a superior predictor for OS and CSS compared with PC.

CONCLUSIONS

RHC could not dissect more positive lymph nodes or provide long-term survival benefits for RCC patients with MAC compared with PC. This study could provide some evidence for surgery treatment selection for MAC of RCC, which has important clinical value in individual management of colon cancer patients.

A Unique Case of Low-Grade Mucinous Neoplasm in Stump Appendectomy

Background

We describe a case of a young male with a history of appendectomy one year ago, who developed symptoms of stump appendicitis, and after removing this stump, histopathology showed low grade neoplasm. Summary. Stump appendicitis is an uncommon complication after appendectomy and may lead to serious complications. Management of low-grade appendiceal mucinous neoplasm (LAMN) is controversial, and we discuss the importance of the case.

Conclusion

The case of young male post stump appendectomy with histopathology showing LAMN in the stump of the appendix, which to our knowledge, is the first in the medical literature and, discuss the stump appendicitis and incomplete appendectomy concerning malignancy, mucinous neoplasm, and adenocarcinoma.

Surgical management of appendiceal mucinous neoplasm: Is appendectomy sufficient?

BACKGROUND AND OBJECTIVES

Due to the rarity of appendiceal mucinous neoplasms (AMNs), there are few established treatment guidelines. The clinical course varies from incidental detection to progressive spread with pseudomyxoma peritonei (PMP). This study investigated the extent of resection on the prognosis and outcomes of AMNs.

METHODS

This multicenter retrospective study evaluated patients with AMN who underwent surgery between 4/2006 to 9/2017. Primary endpoints included overall survival (OS) and disease-specific survival (DSS). Secondary endpoints included PMP incidence and treatment with cytoreductive surgery (CRS).

RESULTS

Of the 138 patients with AMN, 70 patients (54%) underwent appendectomy, 26 (19%) cecectomy, and 37 (27%) right hemicolectomy. The median age was 59.7 years and 57 patients (41%) were male. Males were less likely to undergo cecectomy (P = .03). Rupture rates, tumor characteristics, and incidence of PMP were similar across surgery groups. Median follow-up was 61.3 months. Five-year OS and DSS for the total cohort were 94.9% and 98.6%, respectively, and remained similar across all surgery groups. CRS patients were more likely to undergo right hemicolectomy with no difference in survival by surgery type (P = .03).

CONCLUSIONS

Patients with AMN have a good overall prognosis and there may be minimal benefit to performing extended surgical resection in these patients.

Outcomes Following Cytoreduction and HIPEC for Pseudomyxoma Peritonei: 10-Year Experience

BACKGROUND

Pseudomyxoma peritonei (PMP) is a rare clinical presentation, with considerable morbidity and mortality if left untreated. In recent decades, there is growing acceptance for the use of cytoreductive surgery (CRS) with heated intraperitoneal chemotherapy (HIPEC). The aim of this study was to report on our 10-year single-center experience on outcomes following CRS and HIPEC for PMP of appendiceal origin.

METHODS

A retrospective analysis of a prospectively maintained database of all patients undergoing CRS and HIPEC for PMP of appendiceal origin over a 10-year period at a statewide referral center was conducted.

RESULTS

One hundred and seventy-five cytoreductive procedures were undertaken in 140 patients. The mean patient age was 57.4 years, with a female preponderance (56%). The median PCI was 16, with 73.1% of cases having a complete cytoreduction. Grade III/IV complications occurred in 36 (20.6%) cases, with no mortalities. The median overall and disease-free survival was 100 months and 40 months, respectively, with a 71% 5-year survival. High-grade histology was the main factor identified as an independent predictor of worse overall survival.

CONCLUSION

CRS and HIPEC are safe with acceptable rates of morbidity. It can provide very favorable survival in patients with PMP. High-grade histology is a key prognostic factor associated with a worse overall survival.

Appendiceal tumours and pseudomyxoma peritonei: Literature review with PSOGI/EURACAN clinical practice guidelines for diagnosis and treatment

Pseudomyxoma Peritonei (PMP) is a rare peritoneal malignancy, most commonly originating from a perforated epithelial tumour of the appendix. Given its rarity, randomized controlled trials on treatment strategies are lacking, nor likely to be performed in the foreseeable future. However, many questions regarding the management of appendiceal tumours, especially when accompanied by PMP, remain unanswered. This consensus statement was initiated by members of the Peritoneal Surface Oncology Group International (PSOGI) Executive Committee as part of a global advisory role in the management of uncommon peritoneal malignancies. The manuscript concerns an overview and analysis of the literature on mucinous appendiceal tumours with, or without, PMP. Recommendations are provided based on three Delphi voting rounds with GRADE-based questions amongst a panel of 80 worldwide PMP experts.

A Nomogram for Predicting Lymph Nodal Metastases in Patients with Appendiceal Cancers: An Analysis of SEER Database

BACKGROUNDS

Appendiceal cancers are usually diagnosed after appendectomy accidentally. The need for subsequent right hemicolectomy in these patients was determined by the potential risk of regional lymph node (LN) metastasis. Establishing a nomogram to forecast the potential risk of lymph node metastasis of appendiceal cancer could help in the next step of treatment.

METHODS

Patients with appendiceal cancer undergoing surgery was queried in the American cancer database of Surveillance, Epidemiology and End Results database from 2004 to 2016. A nomogram was established based on Logistic regression model.

RESULTS

Finally, 3,075 patients were diagnosed with appendectomy cancer from 2004 to 2016. Among them, there were 2028 (65.9%) cases with negative lymph nodes, 1047 (34.1%) cases with positive lymph nodes. Risk factors associated with lymph node metastasis include age, histological type, tissue grade, T stage, distant metastasis, and tumor size. We drew the ROC curves of the training group（0.754, P < 0.001） and the validation group （0.775, P < 0.001） respectively. C-index values of predictions were 0.772 (95%CI, 0.750-0.793) and 0.776 (95%CI, 0.746-0.807), and Brier score were 0.178 and 0.172 in training and validation group respectively. All of them showed excellent performance of the nomogram in our study.

CONCLUSION

A new nomogram was created to assess the potential risk of LN metastasis in patients of appendiceal cancer by utilizing age, tumor histology, tumor pathologic grade, tumor size, T-stage, and M-stage. The nomogram could provide a strong reference for the right hemicolectomy and facilitate clinic decision.

Peritoneal Metastases from Appendiceal Cancer

The early symptoms of appendiceal cancer may mimic the clinical picture of appendicitis. Most patients are diagnosed incidentally during surgical exploration or late when peritoneal or systemic dissemination has already occurred, as colonoscopy rarely will diagnose an appendiceal cancer. Systemic/extraperitoneal metastases are distinctly unusual for appendiceal mucinous lesions.

A proposal of Brazilian Society of Surgical Oncology (BSSO/SBCO) for standardizing cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) procedures in Brazil: pseudomixoma peritonei, appendiceal tumors and malignant peritoneal mesothelioma

Cytoreductive surgery plus hypertermic intraperitoneal chemotherapy has emerged as a major comprehensive treatment of peritoneal malignancies and is currently the standard of care for appendiceal epithelial neoplasms and pseudomyxoma peritonei syndrome as well as malignant peritoneal mesothelioma. Unfortunately, there are some worldwide variations of the cytoreductive surgery and hypertermic intraperitoneal chemotherapy techniques since no single technique has so far demonstrated its superiority over the others. Therefore, standardization of practices might enhance better comparisons between outcomes. In these settings, the Brazilian Society of Surgical Oncology considered it important to present a proposal for standardizing cytoreductive surgery plus hypertermic intraperitoneal chemotherapy procedures in Brazil, with a special focus on producing homogeneous data for the developing Brazilian register for peritoneal surface malignancies.

Radical appendectomy as an alternative to right colon resection in patients with epithelial appendiceal neoplasms

OBJECTIVE

Appendectomy is an extremely common surgical procedure usually performed for an inflammatory process within this organ. Upon occasion, the pathology within the appendix is a neoplastic process which requires definitive oncologic management.

METHODS

The optimal management strategies for appendiceal neoplasms were reviewed and pertinent literature critically evaluated. The technology for appendectomy for an inflammatory process and an appendectomy for a neoplastic process were compared and contrasted.

RESULTS

A new surgical procedure called "radical appendectomy" was described and its merits for optimizing the management of an appendiceal neoplasm enumerated. The technology of radical appendectomy was described. The possible shortcomings that may be encountered in performing a new surgical methodology for appendectomy was presented and the results of a technically perfect radical appendectomy enumerated. The integration of a radical appendectomy with perioperative hyperthermic chemotherapy was described.

CONCLUSIONS

When a malignancy exists as the cause of appendiceal pathology, the radical appendectomy will provide the maximal amount of information required for optimal decisions regarding patient management.

Ultimate Clinical Outcomes of Appendiceal Mucinous Neoplasm of Uncertain Malignant Potential

BACKGROUND

The clinical outcome of appendiceal mucinous neoplasm (AMN) is not well understood. This study aimed to compare the long-term outcome for the uncertain malignant potential (UMP) subtype of AMNs with those of the mucinous adenoma (MA) and mucinous adenocarcinoma (MAC) subtypes.

METHODS

In this study, AMNs were classified into three groups (MA, UMP, and MAC), and clinical characteristics, overall survival (OS), and progression-free survival (PFS) were compared among the three groups.

RESULTS

The study included 65 AMN patients (26 MA, 20 UMP, and 19 MAC patients). The median follow-up period was 87 months (range 0.3-311.0) months. The symptoms at diagnosis and the presence of pseudomyxoma peritonei were more common in the MAC group than in the MA group (P = 0.012) or the UMP group (P < 0.001). The 5-year OS rates were 95.5% for the MA group, 93.8% for the UMP group, and 78.3% for the MAC group (P < 0.001), and the 5-year PFS rates were 95.2% for the MA group, 95% for the UMP group, and 36.8% for the MAC group (P < 0.001). Thus, OS and PFS did not differ significantly in the MA and UMP groups (P = 0.884 and 0.345, respectively). In contrast, the OS and PFS of the MAC group were worse than in the MA group (P = 0.017 and <0.001, respectively) or the UMP group (P < 0.001 and 0.001, respectively).

CONCLUSIONS

The long-term outcome for UMP tumors is similar to that for MA tumors and significantly better than for MAC tumors.

When and When Not to Perform a Right Colon Resection with Mucinous Appendiceal Neoplasms

BACKGROUND

Mucinous appendiceal neoplasms (MAN) with peritoneal dissemination is treated as a standard of care using cytoreductive surgery and hyperthermic perioperative chemotherapy. The extent of the resection of peritoneal surfaces and visceral structures is generally well defined. Exception to this consensus regarding structures to be removed are the right colon and adjacent ileocolic lymph nodes.

METHODS

From a prospectively maintained database, all patients with a histologic diagnosis of peritoneal mucinous carcinoma (PMCA) who underwent complete cytoreductive surgery were assessed for the presence versus absence of adenocarcinoma in lymph nodes within the appendiceal mesentery and/or in the lymph nodes of the ileocolic group. The histologic grade of the PMCA was correlated with the incidence of lymph node invasion. Also, in those PMCA patients who had no evidence of lymph node invasion, recurrence within the ileocolic lymph nodes was determined by computed tomography or second look.

RESULTS

In a database of MAN patients, 299 had a histologic diagnosis of PMCA. In well-differentiated (n = 44), moderately differentiated (n = 107), and poorly differentiated (n = 148) PMCA specimens, there were 6.8, 5.6, and 29 % positive lymph nodes, respectively. None of these 151 patients with well- or moderately differentiated PMCA had a computed tomographic scan or clinical evidence by second-look surgery of recurrence within the ileocolic lymph nodes.

CONCLUSIONS

There is a low incidence (6.0 %) of positive lymph nodes in patients with low or moderately differentiated PMCA. With high-grade disease, lymph node invasion increased to 29.0 %. Right colectomy is indicated in patients with high-grade PMCA.

Cytoreductive Surgery and Peritonectomy Procedures

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has become widely accepted as an effective method of treating peritoneal metastases (PM) from various cancers. CRS performed with the goal of removing all the macroscopic disease and comprises of peritonectomy procedures and visceral resections. CRS is a technically challenging surgery that requires a considerable amount of skill and appropriate patient selection. This article is a review of the techniques and current recommendations for performing CRS.

Looking up: Recent advances in understanding and treating peritoneal carcinomatosis

Until recently, a diagnosis of peritoneal carcinomatosis was uniformly accompanied by a grim prognosis that was typically measured in weeks to months. Consequently, the management of carcinomatosis revolves largely around palliation of symptoms such as bowel obstruction, nausea, pain, fatigue, and cachexia. A prior lack of effective treatment options created the nihilistic view that currently exists and persists despite improvements in the efficacy of systemic therapy and the evolution of multimodality approaches including surgery and intraperitoneal chemotherapy. This article reviews the evolution and current state of treatment options for patients with peritoneal carcinomatosis. In addition, it highlights recent advances in understanding the molecular biology of carcinomatosis and the focus of current and future clinical trials. Finally, this article provides practical management options for the palliation of common complications of carcinomatosis. It is hoped that the reader will recognize that carcinomatosis is no longer an imminent death sentence and that through continued research and therapeutic innovation, clinicians can make an even greater impact on this form of metastatic cancer.

Mucinous epithelial neoplasms of the appendix and pseudomyxoma peritonei

The classification of appendiceal mucinous neoplasms has been controversial, largely focused on a particular subset of low-grade mucinous tumors that, despite their innocuous appearance, can disseminate to the peritoneal cavity as pseudomyxoma peritonei (PMP). Recent WHO classification of these tumors as low-grade appendiceal mucinous neoplasms acknowledges their unique morphologic appearance and biologic behavior. Still, debate about the use of this term and its parameters continues to impede the adoption of consensus classification for appendiceal mucinous neoplasms. The classification of PMP has also been the subject of debate, with international authorities advocating for the use of malignant terminology to describe all grades of PMP, even though some authorities consider low-grade PMP to be dissemination of adenomatous epithelium in the peritoneum. Recent data also emphasize the importance of histologic grade of the peritoneal tumors in defining prognosis of these patients.

Significance of proximal margin involvement in low-grade appendiceal mucinous neoplasms

CONTEXT

Appendiceal adenomas and low-grade appendiceal mucinous neoplasms (LAMNs) confined to the appendix are cured by appendectomy. However, involvement of the proximal margin raises concern for residual disease. Some patients with a positive margin at appendectomy undergo cecal resection to eliminate a perceived risk for tumor recurrence or dissemination, although that likelihood is assumed rather than demonstrated.

OBJECTIVE

To determine whether involvement of the proximal appendiceal resection margin by adenoma or LAMN is a risk factor for local development of recurrence or pseudomyxoma peritonei.

DESIGN

Appendiceal adenomas and LAMNs confined to the appendix were considered for the study if they showed neoplasia or dissecting mucin at the proximal margin. The presence or absence of residual tumor in cecal resections was determined. Follow-up data were obtained from clinical records.

RESULTS

Sixteen patients (14 female, 2 male) with LAMN (n = 15) or adenoma (n = 1) and an involved proximal resection margin were identified, including 9 with neoplastic epithelium within the lumen and 7 with acellular mucin in the appendiceal wall at the margin. Six patients underwent cecal resection and the others were nonsurgically followed. No cecal resection had residual neoplasia. No patient developed recurrence or pseudomyxoma peritonei (mean follow-up, 4.7 years).

CONCLUSIONS

In patients with LAMNs confined to the appendix, involvement of the appendectomy margin by neoplastic epithelium or acellular mucin does not predict recurrence of disease, even without further surgery. A conservative approach to managing these patients can be justified.

Female patients with pseudomyxoma peritonei: a single-institution clinicopathologic study of 35 cases

PURPOSE

To explore clinicopathologic/prognostic aspects of pseudomyxoma peritonei (PMP).

METHODS

We reviewed records of 35 female patients with PMP treated at a single institution.

RESULTS

Patients' median age was 57.0 years (range 35.0-71.0 years). Their median pre-surgery level of carbohydrate antigen 19-9 (CA-199) was 80.95 U/ml (range 0.00-1,562.10 U/ml); of carbohydrate antigen 12-5 (CA-125), 44.00 U/ml (range 0.90-231.20 U/ml); and of carcinoembryonic antigen (CEA), 17.20 ng/ml (range 2.04-211.60 ng/ml). Of the 35 patients, 23 (65.7 %) underwent cytoreductive surgery (CRS) by gynecological oncologists and 12 (34.3 %) underwent non-CRS surgeries by general gynecologists or surgeons, including one patient who refused surgical treatment beyond a diagnostic laparoscopy. After surgery, 18 patients (51.4 %) had residual lesions, 11 (31.4 %) had complete lesion removal and 6 (17.1 %)had insufficient information on residual lesion; 21 (60.0 %) had appendiceal-based tumors and 12 (34.3 %) had ovarian-based tumors. Median follow-up time was 37 months (range 1-148 months), during which 28 patients (80.0 %) had relapsed. By the end of the study, 12 patients (34.3 %) died of PMP, 16 (45.7 %) survived with disease, and 7 (20 %) survived without disease. Median progress-free survival (PFS) was 12 months (range 0.5-114.0 months). Median overall survival time was 42 months (range 5-150 months). Ovarian tumor origin, post-surgery residual lesions, preoperative CA199 > 258.9 U/ml and CA125 > 70.6 U/ml were independent predictors of PFS.

CONCLUSIONS

PMP is rare in women, and has a poor long-term survival rate. Multi-center cooperation to gather more cases is needed to explore its behavior and proper treatment.

Right hemicolectomy for mucinous adenocarcinoma of the appendix: just right or too much?

BACKGROUND

The surgical management of mucinous adenocarcinoma of the appendix (MA) is controversial, given its infrequent nodal metastases and its propensity for peritoneal dissemination compared to nonmucinous adenocarcinoma. We sought to identify the appropriateness of a right hemicolectomy (RH) for MA in staging and treatment of these tumors.

METHODS

We queried all patients with MA captured in the Surveillance, Epidemiology, and End Results (SEER) database from 1973 to 2007. Demographics, and tumor and therapy characteristics were extracted. Overall and disease-specific survival was compared by Cox regression analyses.

RESULTS

Of 2,101 patients with MA, the median age was 59 (range 49-72) years; 55 % were women (n = 1,151). Tumor, node, metastasis staging revealed that tumors were frequently T3 (33 %) or T4 (46 %), N0 (80 %), and M1 (46 %). Fifty-one percent (n = 666) of patients underwent an appendectomy. In patients with complete staging information who underwent RH, nodal metastases were less frequent than the nonmucinous adenocarcinoma group (odds ratio 0.63, p = 0.003). Well-differentiated tumors had a low likelihood of nodal metastases (6 % T1, 0 % T2, 7 % T3, 22 % T4). Adjusted survival for patients undergoing appendectomy was similar to those undergoing a RH (hazard ratio 0.93, p = 0.52). Median survival for both groups was similar with positive nodes (28 [appendectomy] vs. 26 months [RH], p = 0.26) or metastatic disease (52 [appendectomy] vs. 43 months [RH], p = 0.28).

CONCLUSIONS

There does not appear to be a therapeutic benefit to a RH in the setting of known node-positive or metastatic disease. Benefits of a staging operation can be individualized on the basis of the probability of nodal metastases, which is lower than nonmucinous tumors.