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Wajih N, Erali RA, Forsythe SD, Schaaf CR, Shen P, Levine EA, Soker S, Morris DL, Votanopoulos KI. Enhancing the Efficacy of HIPEC Through Bromelain: A Preclinical Investigation in Appendiceal Cancer. Ann Surg Oncol 2024; 31:5377-5389. [PMID: 38704503 PMCID: PMC11236891 DOI: 10.1245/s10434-024-15355-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 04/09/2024] [Indexed: 05/06/2024]
Abstract
INTRODUCTION Appendiceal cancer (AC) excessive mucin production is a barrier to heated intraperitoneal chemotherapy (HIPEC) drug delivery. Bromelain is a pineapple stem extract with mucolytic properties. We explored bromelain treatment effects against mucinous AC in a patient-derived tumor organoid (PTO) model and an AC cell line. PATIENTS AND METHODS PTOs were fabricated from tumor specimens obtained from patients with AC undergoing cytoreductive surgery with HIPEC. PTOs underwent HIPEC treatment with bromelain, cisplatin, and mitomycin C (MMC) at 37 °C and 42 °C with and without bromelain pretreatment. RESULTS From October 2020 to May 2023, 16 specimens were collected from 13 patients with low-grade (12/16, 75%) and high-grade AC (4/16, 25%). The mucin-depleting effects of bromelain were most significant in combination with N-acetylcysteine (NAC) compared with bromelain (47% versus 10%, p = 0.0009) or NAC alone (47% versus 12.8%, p = 0.0027). Bromelain demonstrated > 31% organoid viability reduction at 60 min (p < 0.001) and > 66% in 48 h (p < 0.0001). Pretreatment with bromelain increased cytotoxicity of both cisplatin and MMC HIPEC conditions by 31.6% (p = 0.0001) and 35.5% (p = 0.0001), respectively. Ki67, CK20, and MUC2 expression decreased after bromelain treatment; while increased caspase 3/7 activity and decreased Bcl-2 (p = 0.009) and Bcl-xL (p = 0.01) suggest induction of apoptosis pathways. Furthermore, autophagy proteins LC3A/B I (p < 0.03) and II (p < 0.031) were increased; while ATG7 (p < 0.01), ATG 12 (p < 0.04), and Becline 1(p < 0.03), expression decreased in bromelain-treated PTOs. CONCLUSIONS Bromelain demonstrates cytotoxicity and mucolytic activity against appendiceal cancer organoids. As a pretreatment agent, it potentiates the cytotoxicity of multiple HIPEC regimens, potentially mediated through programmed cell death and autophagy.
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Affiliation(s)
- Nadeem Wajih
- Wake Forest Department of General Surgery, Wake Forest Organoid Research Center (WFORCE), Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Wake Forest Institute of Regenerative Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Richard A Erali
- Wake Forest Department of General Surgery, Wake Forest Organoid Research Center (WFORCE), Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Wake Forest Institute of Regenerative Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Section of Surgical Oncology, Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Steven D Forsythe
- Wake Forest Department of General Surgery, Wake Forest Organoid Research Center (WFORCE), Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Wake Forest Institute of Regenerative Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Wake Forest Comprehensive Cancer Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Department of Cancer Biology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Cecilia R Schaaf
- Wake Forest Department of General Surgery, Wake Forest Organoid Research Center (WFORCE), Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Wake Forest Institute of Regenerative Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Department of Comparative Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Perry Shen
- Section of Surgical Oncology, Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Edward A Levine
- Section of Surgical Oncology, Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Shay Soker
- Wake Forest Department of General Surgery, Wake Forest Organoid Research Center (WFORCE), Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Wake Forest Institute of Regenerative Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - David L Morris
- Department of Surgery, St. George Hospital, University of New South Wales, Sydney, Australia
| | - Konstantinos I Votanopoulos
- Wake Forest Department of General Surgery, Wake Forest Organoid Research Center (WFORCE), Wake Forest University School of Medicine, Winston-Salem, NC, USA.
- Wake Forest Institute of Regenerative Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
- Wake Forest Comprehensive Cancer Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
- Section of Surgical Oncology, Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
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Ayala-de Miguel C, Jiménez-Castro J, Sánchez-Vegas A, Díaz-López S, Chaves-Conde M. Neoplastic appendiceal mucinous lesions: a narrative review of the literature from an oncologist's perspective. Clin Transl Oncol 2024; 26:1287-1299. [PMID: 38070049 DOI: 10.1007/s12094-023-03356-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 11/14/2023] [Indexed: 05/22/2024]
Abstract
Appendiceal mucinous lesions' classification and nomenclature has been modified several times along the last decades, reflecting their great heterogeneity and making difficult to compare results and draw conclusions. Despite its nearby origin, appendiceal mucinous lesions have a distinctive behaviour compared to colorectal cancer, including their molecular and genetic markers. Due to their low frequency, their management is not well standardised. However, surgery is considered the cornerstone of treatment. Their indolent behaviour has encouraged surgeons to apply more aggressive treatments, such as cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC), that may extend overall survival. Chemotherapy is reserved for unresectable and/or disseminated disease and could play a role in the adjuvant and neoadjuvant setting. Pressurised intraperitoneal aerosol chemotherapy (PIPAC) is recently emerging as a possible alternative for treatment in advanced disease although its results in long-term survival are lacking Hereby, we review the available evidence in the management of appendiceal mucinous lesions, including localised and disseminated disease, with a special emphasis on the oncological perspective, focusing on the lights and shadows of the systemic treatments.
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Affiliation(s)
- Carlos Ayala-de Miguel
- Servicio Oncología Médica, Hospital Universitario Valme, Ctra. de Cádiz Km 548,9, C.P.: 41014, Seville, Spain
| | - Jerónimo Jiménez-Castro
- Servicio Oncología Médica, Hospital Universitario Valme, Ctra. de Cádiz Km 548,9, C.P.: 41014, Seville, Spain.
| | - Adrián Sánchez-Vegas
- Servicio Oncología Médica, Hospital Universitario Valme, Ctra. de Cádiz Km 548,9, C.P.: 41014, Seville, Spain
| | - Sebastián Díaz-López
- Servicio Oncología Médica, Hospital Universitario Valme, Ctra. de Cádiz Km 548,9, C.P.: 41014, Seville, Spain
| | - Manuel Chaves-Conde
- Servicio Oncología Médica, Hospital Universitario Valme, Ctra. de Cádiz Km 548,9, C.P.: 41014, Seville, Spain
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Cho HJ, Kim JW, Kim WR. Is cytoreductive surgery and hyperthermic intraperitoneal chemotherapy still beneficial in patients diagnosed with colorectal peritoneal metastasis who underwent palliative chemotherapy? Asian J Surg 2024; 47:296-302. [PMID: 37648541 DOI: 10.1016/j.asjsur.2023.08.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 07/05/2023] [Accepted: 08/22/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND With a 5-year overall survival of less than 5%, colorectal peritoneal metastasis (CPM) patients are often managed with palliative chemotherapy (CTx). In the past few decades, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has been introduced as a possible curative treatment for highly selective CPM patients. We share our experience of CRS and HIPEC given the unique characteristics of the medical system and the benefit of CRS and HIPEC in palliative setting. METHODS From April 2017 to October 2021, CPM patients who underwent CRS and HIPEC were analyzed. Patients were allocated into perioperative and palliative CTx arm based on the duration between initial diagnosis of CPM to undergoing CRS and HIPEC of 6 months. Data including perioperative parameters, postoperative outcomes, and survival were analyzed with a median follow-up of 28.5 months. RESULTS Twenty-six CPM patients underwent CRS and HIPEC. Mean time from diagnosis of CPM to CRS and HIPEC was 5.5 months with 14 patients in the perioperative arm and 12 patients in the palliative arm. Perioperative group showed a longer RFS of 13.5 months compared to 8 months in the palliative group. Median overall survival of palliative group was 41.50 months, and 18 patients among all groups are alive at the time of this report. CONCLUSION CRS and HIPEC could be a treatment option for a carefully selected CPM patients performed by experienced surgeons. Overall survival of 41.50 months in palliative group compared to 16.8 months from conventional systemic CTx supports CRS and HIPEC even in palliative patients.
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Affiliation(s)
- Hye Jung Cho
- Division of Colorectal Surgery, Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Woo Kim
- Division of Colorectal Surgery, Department of Surgery, Bundang CHA Medical Center, CHA University College of Medicine, Seongnam, Republic of Korea
| | - Woo Ram Kim
- Division of Colorectal Surgery, Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Chandramohan D, Mohamed F, Vikram S, Damodaran D, Shamsudeen S, Rahman F, Alapatt JJ, Krishnan GR, Dayananda R, Shahid MP, Das AP, Varghese J, Bhatt A, Damodaran D. Standardised Critical Care Strategies Improve Outcomes Following Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy in an Indian Peritoneal Malignancy Centre. Indian J Surg Oncol 2023; 14:920-927. [PMID: 38187832 PMCID: PMC10766987 DOI: 10.1007/s13193-023-01803-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/14/2023] [Indexed: 01/09/2024] Open
Abstract
Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a major undertaking with profound peri-operative metabolic and haemodynamic alterations. It requires standardised protocols for immediate postoperative intensive care management to improve patient-related outcomes. A retrospective analysis of a prospectively maintained data-base of 244 patients who underwent CRS and HIPEC between June 2017 and July 2022 in our institute was done. Based on the audit, six strategies were implemented, namely, (1) dynamic multiparameter-based IVF therapy to aggressively correct the hyperlactatemia, (2) initiation of IV 20% human albumin infusion from POD-0, (3) correction of serum iCa2+ levels, (4) initiation of diuresis from POD-1, (5) prophylactic use of HFNO immediately post-extubation and (6) serum procalcitonin level-based empiric escalation of IV antibiotics. Patients were divided into two cohorts, pre-protocol group of 145 patients (from June 2017 to December 2020) and post-protocol group comprising of 99 patients (from January 2021 to July 2022), and were analysed for compliance and patient-related outcomes. Implementation of these strategies improved the patient-related outcomes among the two cohorts with significant reduction of Clavien-Dindo grade III/IV complications and improvement in failure to rescue (FTR) index (p < 0.05). There was highly significant reduction in median ICU and hospital stay among the two cohorts (p < 0.001). The formulated protocols of management strategies especially multiparameter-based dynamic fluid therapy, planned diuresis and prophylactic HFNO have improved the outcomes in our patients undergoing CRS and HIPEC.
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Affiliation(s)
- Deepa Chandramohan
- Department of Critical Care, MVR Cancer Centre and Research Institute, Kozhikode, Kerala India
| | - Faheez Mohamed
- Peritoneal Malignancy Institute, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - Syam Vikram
- Department of Surgical Oncology, MVR Cancer Centre and Research Institute, Kozhikode, Kerala India
| | - Deepak Damodaran
- Department of Surgical Oncology, MVR Cancer Centre and Research Institute, Kozhikode, Kerala India
| | - Shafeek Shamsudeen
- Department of Surgical Oncology, MVR Cancer Centre and Research Institute, Kozhikode, Kerala India
| | - Faslu Rahman
- Department of Surgical Oncology, MVR Cancer Centre and Research Institute, Kozhikode, Kerala India
| | - John J. Alapatt
- Department of Surgical Oncology, MVR Cancer Centre and Research Institute, Kozhikode, Kerala India
| | - Gokul R. Krishnan
- Department of Surgical Oncology, MVR Cancer Centre and Research Institute, Kozhikode, Kerala India
| | - R Dayananda
- Department of Surgical Oncology, MVR Cancer Centre and Research Institute, Kozhikode, Kerala India
| | - Muhammed P. Shahid
- Department of Critical Care, MVR Cancer Centre and Research Institute, Kozhikode, Kerala India
| | - Arun P. Das
- Department of Critical Care, MVR Cancer Centre and Research Institute, Kozhikode, Kerala India
| | - Jinu Varghese
- Department of Critical Care, MVR Cancer Centre and Research Institute, Kozhikode, Kerala India
| | - Aditi Bhatt
- Department of Surgical Oncology, KD Hospital, Ahmedabad, Gujarat India
| | - Dileep Damodaran
- Department of Surgical Oncology, MVR Cancer Centre and Research Institute, Kozhikode, Kerala India
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Strach MC, Chakrabarty B, Nagaraju RT, Mullamitha S, Braun M, O'Dwyer ST, Aziz O, Barriuso J. Defining a role for systemic chemotherapy in local and advanced appendix adenocarcinoma. ESMO Open 2023; 8:101619. [PMID: 37625193 PMCID: PMC10619141 DOI: 10.1016/j.esmoop.2023.101619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/18/2023] [Accepted: 07/20/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Appendix adenocarcinomas (AAs) are rare tumours that often present late, with a propensity for peritoneal metastases (PMs). This study aimed to evaluate outcomes of AA patients undergoing cytoreductive surgery (CRS) with curative intent and determine the role of systemic chemotherapy. MATERIALS AND METHODS Data were collected from a prospective database and classified according to World Health Organization (WHO) 2019 classification. Tumour clearance from CRS was described using a completeness of cytoreduction (CC) score ranging from 0 [no residual disease (RD)] to 3 (>2.5 cm RD). Patients with CC0-2 CRS received hyperthermic intraperitoneal chemotherapy (HIPEC). Systemic chemotherapy was categorised as 'prior' (>6 months before), 'neoadjuvant' (<6 months before), 'adjuvant' (<6 months after CC0-1 CRS) or 'palliative' (after CC2-3 CRS). Analyses used Kaplan-Meier and Cox regression methods. RESULTS Between January 2005 and August 2021, 216 AA patients were identified for inclusion. Median age was 59 years (21-81 years). CRS/HIPEC was carried out in 182 (84%) patients, of whom 164/182 (76%) had mitomycin C HIPEC. CC0-1 was achieved in 172 (80%) patients. Systemic chemotherapy was given to 97 (45%) patients from the whole cohort and to 37/46 (80%) patients with positive nodes. Median overall survival (OS) was 122 months (95% confidence interval 61-182 months). After multivariate analysis, patients with acellular and lower-grade PM had similar OS to those with localised (M0) disease (P = 0.59 and P = 0.19). For patients with positive nodes, systemic chemotherapy was associated with reduced risk of death compared to no chemotherapy (P < 0.0019). CONCLUSION This study identifies AA patients with positive lymph nodes derive the most benefit from systemic chemotherapy. We confirm the prognostic importance of stage and peritoneal grade, with excellent outcomes in patients with acellular mucin and lower-grade PM.
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Affiliation(s)
- M C Strach
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Manchester; Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Faculty of Medicine and Health, The University of Sydney, Darlington, Australia.
| | - B Chakrabarty
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Manchester; Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Department of Pathology, The Christie NHS Foundation Trust, Manchester, UK
| | - R T Nagaraju
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Manchester; Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - S Mullamitha
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Manchester
| | - M Braun
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Manchester; Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - S T O'Dwyer
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Manchester; Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - O Aziz
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Manchester; Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - J Barriuso
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Manchester; Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
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SenthilKumar G, Kothari AN, Maduekwe UN, Fournier K, Abbott DE, Wilson GC, Patel SH, Greer J, Johnston F, Dineen SP, Powers BD, Baumgartner J, Veerapong J, Leiting J, Grotz TE, Maithel SK, Staley C, Raoof M, Lambert L, Lee A, Kim A, Cloyd JM, Mogal H. Validation of the AJCC 8th Edition Staging System for Disseminated Appendiceal Cancer Patients Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: A Multi-institutional Analysis. Ann Surg Oncol 2023; 30:5743-5753. [PMID: 37294386 DOI: 10.1245/s10434-023-13697-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/17/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND The AJCC 8th edition stratifies stage IV disseminated appendiceal cancer (dAC) patients based on grade and pathology. This study was designed to externally validate the staging system and to identify predictors of long-term survival. METHODS A 12-institution cohort of dAC patients treated with CRS ± HIPEC was retrospectively analyzed. Overall survival (OS) and recurrence-free survival (RFS) were analyzed by using Kaplan-Meier and log-rank tests. Univariate and multivariate cox-regression was performed to assess factors associated with OS and RFS. RESULTS Among 1009 patients, 708 had stage IVA and 301 had stage IVB disease. Median OS (120.4 mo vs. 47.2 mo) and RFS (79.3 mo vs. 19.8 mo) was significantly higher in stage IVA compared with IVB patients (p < 0.0001). RFS was greater among IVA-M1a (acellular mucin only) than IV M1b/G1 (well-differentiated cellular dissemination) patients (NR vs. 64 mo, p = 0.0004). Survival significantly differed between mucinous and nonmucinous tumors (OS 106.1 mo vs. 41.0 mo; RFS 46.7 mo vs. 21.2 mo, p < 0.05), and OS differed between well, moderate, and poorly differentiated (120.4 mo vs. 56.3 mo vs. 32.9 mo, p < 0.05). Both stage and grade were independent predictors of OS and RFS on multivariate analysis. Acellular mucin and mucinous histology were associated with better OS and RFS on univariate analysis only. CONCLUSIONS AJCC 8th edition performed well in predicting outcomes in this large cohort of dAC patients treated with CRS ± HIPEC. Separation of stage IVA patients based on the presence of acellular mucin improved prognostication, which may inform treatment and long-term, follow-up strategies.
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Affiliation(s)
- Gopika SenthilKumar
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Anai N Kothari
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ugwuji N Maduekwe
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Keith Fournier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Daniel E Abbott
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Gregory C Wilson
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sameer H Patel
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jonathan Greer
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Fabian Johnston
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Sean P Dineen
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, and Department of Oncologic Sciences, Morsani College of Medicine, Tampa, FL, USA
| | - Benjamin D Powers
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, and Department of Oncologic Sciences, Morsani College of Medicine, Tampa, FL, USA
| | - Joel Baumgartner
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, CA, USA
| | - Jula Veerapong
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, CA, USA
| | - Jennifer Leiting
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Travis E Grotz
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Charles Staley
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Mustafa Raoof
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Laura Lambert
- Department of Surgery, University of Utah Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - Andrew Lee
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alex Kim
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jordan M Cloyd
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Harveshp Mogal
- Department of Surgery, University of Washington Medical Center, Seattle, WA, USA.
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González Bayón L, Martín Román L, Lominchar PL. Appendiceal Mucinous Neoplasms: From Clinic to Pathology and Prognosis. Cancers (Basel) 2023; 15:3426. [PMID: 37444536 DOI: 10.3390/cancers15133426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/20/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
Appendiceal mucinous neoplasms have been classified differently over time causing confusion when comparing results between working groups in this field and establishing a prognosis of the disease. A historical perspective of the different classification systems of these tumors is essential for the understanding of the evolution of concepts and histopathological definitions that have led up to the present moment. We carried out a systematic review of the pathological classifications of appendiceal mucinous tumors and how they have included the new criteria resulting from clinical and pathological research. The latest classifications by PSOGI and AJCC 8th edition Cancer Staging have made a great effort to incorporate the new pathological descriptions and develop prognostic groups. The introduction of these new classification systems has posed the challenge of verifying how they adapt to our casuistry and which one defines best the prognosis of our patients. We reclassified our series of patients treated for mucinous appendiceal tumors with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy following the PSOGI and the AJCC 8th edition criteria and concluded that both classifications correspond well with the OS and DFS of these patients, with some advantage relative to the PSOGI classification due to a better histopathological description of the different groups.
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Affiliation(s)
- Luis González Bayón
- Peritoneal Carcinomatosis Unit, Department of General Surgery, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain
- Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Lorena Martín Román
- Peritoneal Carcinomatosis Unit, Department of General Surgery, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain
- Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Pablo Lozano Lominchar
- Peritoneal Carcinomatosis Unit, Department of General Surgery, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain
- Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain
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Goffredo P, Aguirre N, Mohamed M, Kleiman DA, Cercek A, Joshua Smith J, Paty PB, Weiser M, Garcia-Aguilar J, Nash GM. Incomplete cytoreductive surgery for appendiceal and colorectal peritoneal carcinomatosis: Characteristics and outcomes of an overlooked group. J Surg Oncol 2023; 127:1028-1034. [PMID: 36862078 PMCID: PMC10079630 DOI: 10.1002/jso.27223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 02/18/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND OND OBJECTIVES Complete cytoreductive surgery (CRS) may prolong survival for selected patients with peritoneal carcinomatosis from colorectal cancer (CRC). However, there is a paucity of data on outcomes following incomplete procedures. METHODS Patients with incomplete CRS for well-differentiated (WD) and moderate/poorly-differentiated (M/PD) appendiceal cancer, right and left CRC were identified at a single tertiary center (2008-2021). RESULTS Of 109 patients, 10% were WD and 51% M/PD appendiceal cancers, and 16% right and 23% left CRC. There were no differences in gender, BMI (mean = 27), ASA score, previous abdominal surgery (72%), and extent of CRS. The PC Index differed between appendiceal and colorectal cancers (mean = 27 vs. 17, p < 0.01). Overall, the perioperative outcomes were similar among the groups, with 15% experiencing complications. Postoperatively, 61% received chemotherapy, and 51% required ≥1 subsequent procedure. The 1 and 3-year survival for the WD, M/PD, right and left CRC subgroups were 100%, 67%, 44%, 51%, and 88%, 17%, 12%, and 23%, respectively (p = 0.02). CONCLUSIONS Incomplete CRS was associated with significant morbidity and number of subsequent palliative procedures. Prognosis correlated with histologic subtype; WD appendiceal cancer patients having superior outcomes, while those with right sided CRC the worst survival. These data may help guiding expectations in the setting of incomplete procedures.
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Affiliation(s)
- Paolo Goffredo
- Department of Surgery, Memorial Sloan Kettering Cancer Center New York, New York, New York, USA
| | - Nicole Aguirre
- Department of Surgery, Memorial Sloan Kettering Cancer Center New York, New York, New York, USA
| | - Mostafa Mohamed
- Department of Surgery, Memorial Sloan Kettering Cancer Center New York, New York, New York, USA
| | - David A Kleiman
- Department of Surgery, Memorial Sloan Kettering Cancer Center New York, New York, New York, USA
| | - Andrea Cercek
- Department of Surgery, Memorial Sloan Kettering Cancer Center New York, New York, New York, USA
| | - J Joshua Smith
- Department of Surgery, Memorial Sloan Kettering Cancer Center New York, New York, New York, USA
| | - Philip B Paty
- Department of Surgery, Memorial Sloan Kettering Cancer Center New York, New York, New York, USA
| | - Martin Weiser
- Department of Surgery, Memorial Sloan Kettering Cancer Center New York, New York, New York, USA
| | - Julio Garcia-Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Center New York, New York, New York, USA
| | - Garrett M Nash
- Department of Surgery, Memorial Sloan Kettering Cancer Center New York, New York, New York, USA
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Mangieri CW, Valenzuela CD, Solsky IB, Erali RA, Votanopoulos KI, Shen P, Levine EA. Impact of myometrium invasion on survival outcomes following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). J Surg Oncol 2023; 127:450-456. [PMID: 36285743 PMCID: PMC10065224 DOI: 10.1002/jso.27122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 09/01/2022] [Accepted: 09/18/2022] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is an effective surgical intervention for peritoneal surface malignancy. The effect of myometrium invasion on outcomes is unknown. METHODS Retrospective review of our institutional registry with analysis of CRS-HIPEC cases involving a hysterectomy. Compared cases with myometrium invasion versus those without invasion. Primary outcome was survival as measured by overall survival (OS) and disease-free survival (DFS). Secondary outcome was the evaluation of risk factors for myometrium invasion based on multivariate analysis. RESULTS A total of 126 cases of CRS-HIPEC involving a hysterectomy were identified. Ninety-seven cases (76.9%) had no myometrium invasion and the remaining 29 cases (23.1%) had malignant invasion. The presence of myometrial invasion was a significant negative survival prognostic factor. The OS was halved with mean survival times of 2.8 (±2.3) versus 5.8 (±4.7) years for cases with and without invasion, respectively (p = 0.002). Five-year OS rates were also inferior with myometrium invasion at 17.4% versus 53.8% (odds ratio [OR] = 0.181, 95% confidence interval [CI]: 0.057-0.580, p = 0.002). A similar trend was present with DFS with mean survival times of 1.4 (±0.9) versus 3.7 (±3.9) years for noninvasion and invasion cases (p = 0.009). The 5-year DFS rates were 0% versus 34.8% (OR = 0.652, 95% CI: 0.549-0.775, p = 0.004). Secondary analysis significantly associated several risk factors with myometrium invasion to include lymph node positivity (OR = 2.539, 95% CI: 1.074-6.003, p = 0.012), colorectal primary tumors (OR = 2.248, 95% CI: 1.094-5.161, p = 0.035), and high-grade tumors (OR = 2.160, 95% CI: 1.080-4.820, p = 0.038). CONCLUSION Myometrium invasion is a significant negative prognostic factor for survival following CRS-HIPEC. Several risk factors are potentially predictive of identifying those at high-risk for myometrium invasion.
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Affiliation(s)
| | | | - Ian B. Solsky
- Wake Forest Baptist Health Medical Center, Section of Surgical Oncology
| | - Richard A. Erali
- Wake Forest Baptist Health Medical Center, Section of Surgical Oncology
| | | | - Perry Shen
- Wake Forest Baptist Health Medical Center, Section of Surgical Oncology
| | - Edward A. Levine
- Wake Forest Baptist Health Medical Center, Section of Surgical Oncology
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Baron E, Sardi A, King MC, Nikiforchin A, Lopez-Ramirez F, Nieroda C, Gushchin V, Ledakis P. Adjuvant chemotherapy for high-grade appendiceal cancer after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:179-187. [PMID: 36253240 DOI: 10.1016/j.ejso.2022.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 07/29/2022] [Accepted: 08/21/2022] [Indexed: 01/24/2023]
Abstract
INTRODUCTION There are no available data on the efficacy of adjuvant chemotherapy (ACT) in stage IVA/B high-grade mucinous appendiceal cancer treated with CRS/HIPEC. We evaluated the association between ACT and survival in this cohort. MATERIALS AND METHODS A single-institution retrospective cohort study using a prospective database was conducted. Stage IVA/B high-grade mucinous appendiceal cancer patients who underwent CRS/HIPEC with CC-0/1 were included. Survival was compared between ACT and no chemotherapy (NoCT) patients. Subgroup analysis was performed with adjustment for confounding variables. RESULTS We identified 180 patients: 77 ACT and 103 NoCT. ACT regimens included 5-FU/capecitabine (13%), oxaliplatin-based (63%), and irinotecan-based (21%), combined with bevacizumab in 27% of cases. Median number of cycles was 9 (IQR: 6-12). Median overall survival (OS) did not significantly differ between ACT and NoCT (53 vs 75 months, p = 0.566). Multivariable Cox regression showed no OS benefit for ACT vs NoCT in patients with neoadjuvant chemotherapy (HR 1.14; 95%CI: 0.38-3.39) or without it (HR 1.33; 95%CI: 0.69-2.57), with signet ring cell (HR 0.89; 95%CI: 0.38-2.06) or other histologies (HR 1.11; 95%CI: 0.50-2.46), positive lymph nodes (HR 1.60; 95%CI: 0.74-3.49), or peritoneal cancer index ≥20 (HR 1.08; 95%CI: 0.55-2.11) after adjusting for other factors. CONCLUSIONS In our cohort, colon-type ACT was not associated with better OS in stage IVA/B mucinous appendiceal cancer after CRS/HIPEC, even after adjusting for confounders. This may be due to different tumor biology than colon cancer or small sample size. Prospective collaborative studies are needed.
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Affiliation(s)
- Ekaterina Baron
- Surgical Oncology Department, The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, 21202, USA
| | - Armando Sardi
- Surgical Oncology Department, The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, 21202, USA.
| | - Mary Caitlin King
- Surgical Oncology Department, The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, 21202, USA
| | - Andrei Nikiforchin
- Surgical Oncology Department, The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, 21202, USA
| | - Felipe Lopez-Ramirez
- Surgical Oncology Department, The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, 21202, USA
| | - Carol Nieroda
- Surgical Oncology Department, The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, 21202, USA
| | - Vadim Gushchin
- Surgical Oncology Department, The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, 21202, USA
| | - Panayotis Ledakis
- Medical Oncology & Hematology Department, The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, 21202, USA
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11
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Sugarbaker PH, Chang D. Extent of Disease on Visceral Peritoneal Surfaces of Mucinous Appendiceal Neoplasms Controls Survival. ANNALS OF SURGERY OPEN 2022; 3:e193. [PMID: 37601148 PMCID: PMC10431514 DOI: 10.1097/as9.0000000000000193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 06/28/2022] [Indexed: 11/26/2022] Open
Abstract
Objective To determine causes of treatment failure of low-grade appendiceal mucinous neoplasms (LAMN). Background For 3 decades, LAMN have been treated by cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy. This combined treatment has resulted in a large change in the survival of these patients. Methods A retrospective review of a prospectively maintained database was performed. A restricted cohort of patients with only LAMN histology and complete CRS were included in the statistical analysis. Results Four hundred and fifty patients were available with a median follow-up of 15.3 years (range 10-35 years). The median age was 49.7 and there were 196 males (43.6%). The mean survival was 24.5 years. Extent of parietal peritonectomy, resection of uterus, ovaries and apex of vagina had no impact on survival. Variables that indicated an increased extent of disease on visceral peritoneal surfaces had a significant impact on survival. Early postoperative intraperitoneal chemotherapy with 5-fluorouracil did not augment hyperthermic intraperitoneal chemotherapy (HIPEC). Patients who required reoperation for recurrence or patients with class 4 adverse events had a reduced prognosis. Conclusions The mean survival of LAMN treated by complete CRS and perioperative chemotherapy was 24.5 years. Extent of disease quantitated on visceral peritoneal surfaces by the extent of visceral resections was the variable associated with treatment failure. Peritonectomy plus HIPEC was able to control disease on parietal peritoneal surfaces. Not only a larger extent of disease but also its location on visceral peritoneal surfaces controlled survival.
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Affiliation(s)
- Paul H. Sugarbaker
- From the Washington Cancer Institute, Program in Peritoneal Surface Malignancy Washington, DC
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12
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Strach MC, Sutherland S, Horvath LG, Mahon K. The role of chemotherapy in the treatment of advanced appendiceal cancers: summary of the literature and future directions. Ther Adv Med Oncol 2022; 14:17588359221112478. [PMID: 35898968 PMCID: PMC9310237 DOI: 10.1177/17588359221112478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 06/20/2022] [Indexed: 11/16/2022] Open
Abstract
Appendiceal cancer is rare and encompasses a diverse group of tumours ranging from low-grade appendiceal mucinous neoplasms to high-grade adenocarcinomas. Appendiceal cancers often spread to the peritoneal cavity causing extensive mucinous dissemination and peritoneal metastases. Prognosis varies with histological subtype. Cytoreductive surgery and heated intraperitoneal chemotherapy is well-established as the most effective treatment achieving long-term survival in some patients. Chemotherapy regimens used to treat appendiceal cancer are extrapolated from the colorectal cancer setting, but disease biology differs and outcomes are inferior. The role of chemotherapy in the treatment of appendiceal cancer remains poorly defined. There is an urgent need to develop novel tailored treatment strategies in the perioperative and unresectable setting. This review aims to evaluate the literature for patients who received intraperitoneal and systemic chemotherapy for appendiceal cancers.
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Affiliation(s)
| | | | | | - Kate Mahon
- Chris O'Brien Lifehouse, 119-144 Missenden Road, Camperdown, NSW 2050, Australia
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13
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Votanopoulos KI. Repeat CRS/HIPEC: It Comes Down to Tumor Biology and Ability to Achieve a Complete CRS. Ann Surg Oncol 2022; 29:3366-3368. [PMID: 35181813 PMCID: PMC9115043 DOI: 10.1245/s10434-022-11429-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 01/26/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Konstantinos I Votanopoulos
- Department of Surgery, Division of Surgical Oncology, Medical Center Boulevard, Wake Forest University, Winston Salem, NC, USA.
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14
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Pletcher E, Gleeson E, Shaltiel T, Leigh N, Sullivan B, Labow D, Magge D, Golas B, Cohen N, Sarpel U. Lymphocyte-to-monocyte ratio predicts survival after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Biomark Med 2021; 15:965-975. [PMID: 34289740 DOI: 10.2217/bmm-2020-0720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Lymphocyte-to-monocyte ratio (LMR) predicts overall survival (OS) in patients with colorectal cancer. We explored LMR in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). Materials & methods: We identified all patients undergoing CRS/HIPEC for colorectal or appendiceal adenocarcinoma at our institution. We analyzed LMR's relationship with clinicopathologic variables with Kaplan-Meier log-rank survival analyses and multivariable Cox regression models with 5-year OS. Results: Two hundred and sixteen patients underwent CRS/HIPEC. Five-year OS for low LMR (≤3.71) was 35.2 versus 60.4% for elevated LMR (hazard ratio [HR]: 2.0; 95% CI: 1.1-3.5; p = 0.02). On multivariable Cox-regression, elevated LMR was significantly associated with OS (p ≤ 0.05). Conclusion: LMR is an independent predictor of OS in patients undergoing CRS/HIPEC for colorectal and appendiceal adenocarcinoma.
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Affiliation(s)
- Eric Pletcher
- Division of Surgical Oncology, Department of Surgery, Mount Sinai West, NY 10019, USA
| | - Elizabeth Gleeson
- Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, NY 10029, USA
| | - Tali Shaltiel
- Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, NY 10029, USA
| | - Natasha Leigh
- Division of Surgical Oncology, Department of Surgery, Mount Sinai West, NY 10019, USA
| | - Brianne Sullivan
- Division of Surgical Oncology, Department of Surgery, Mount Sinai West, NY 10019, USA
| | - Daniel Labow
- Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, NY 10029, USA
| | - Deepa Magge
- Division of Surgical Oncology, Department of Surgery, Mount Sinai West, NY 10019, USA
| | - Benjamin Golas
- Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, NY 10029, USA
| | - Noah Cohen
- Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, NY 10029, USA
| | - Umut Sarpel
- Division of Surgical Oncology, Department of Surgery, Icahn School of Medicine at Mount Sinai, NY 10029, USA
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15
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Ward EP, Okamuro L, Khan S, Hosseini M, Valasek MA, Ronquillo N, Kelly KJ, Veerapong J, Lowy AM, Baumgartner J. Ki67 does not predict recurrence for low-grade appendiceal mucinous neoplasms with peritoneal dissemination after cytoreductive surgery and HIPEC. Hum Pathol 2021; 113:104-110. [PMID: 33905776 DOI: 10.1016/j.humpath.2021.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 11/19/2022]
Abstract
Low-grade appendiceal mucinous neoplasms (LAMN) can disseminate to become low-grade mucinous carcinoma peritonei (LGMCP), which is optimally treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). Approximately half of the patients with LGMCP recur despite complete cytoreduction, and risk factors for recurrence are poorly understood. We sought to evaluate if Ki67 predicts progression of LGMCP after CRS/HIPEC. A retrospective review of a prospectively maintained database was performed to identify patients treated with complete CRS/HIPEC for LGMCP from 2008 to 2019 with Ki67 assessed. Patient characteristics, histologic data, average and focally high "hotspot") Ki67 index, progression-free survival (PFS), and overall survival (OS) were analyzed. Ki-67 immunostain was performed on the histologic section with the highest cellularity and architectural complexity. Forty-four patients with LGMCP (55% male, median age 61) were identified. The median Ki67 score and hotspot Ki67 score was 15% (1-70) and 50% (1-90), respectively. On univariate analysis, average Ki67 and hotspot Ki67 were not predictive of PFS when analyzed as continuous normalized values (HR 1.0, p = 0.79 and HR 1.1, p = 0.38, respectively) or as categorical values when stratified by the median (HR 0.9, p = 0.67 and HR 1.0, p = 0.93). This remained true on multivariate analysis when stratified for peritoneal cancer index, CEA, and completeness of cytoreduction score for both normalized Ki67 and hotspot Ki67 (HR 0.9 [95% CI 0.8-1.3], p = 0.94 and HR 1.04 [95% CI 0.8-1.3], p = 0.73, respectively). Ki67 failed to predict disease recurrence for patients with LGMCP in this cohort.
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Affiliation(s)
| | | | - Sohini Khan
- University of California San Diego, 92037, USA
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16
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Hoehn RS, Rieser CJ, Choudry MH, Melnitchouk N, Hechtman J, Bahary N. Current Management of Appendiceal Neoplasms. Am Soc Clin Oncol Educ Book 2021; 41:1-15. [PMID: 33770459 DOI: 10.1200/edbk_321009] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Appendiceal neoplasms include a heterogeneous group of epithelial and nonepithelial tumors that exhibit varying malignant potential. This review article summarizes current diagnostic criteria, classification systems, and optimal therapeutic strategies for the five main histopathologic subtypes of appendiceal neoplasms. In particular, the management of epithelial appendiceal neoplasms has evolved. Although their treatment has historically been extrapolated from colon cancer, improved understanding of their unique histopathologic and molecular characteristics and a growing body of published clinical data support a more nuanced approach to their management.
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Affiliation(s)
- Richard S Hoehn
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Caroline J Rieser
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - M Haroon Choudry
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Nelya Melnitchouk
- Division of Surgical Oncology, Brigham and Women's Hospital, Boston, MA
| | - Jaclyn Hechtman
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nathan Bahary
- Division of Medical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
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17
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Rozich NS, Lewis SE, Chen S, Stewart KE, Stout MB, Dooley WC, Fischer LE, Morris KT. Women survive longer than men undergoing cytoreductive surgery and HIPEC for appendiceal cancer. PLoS One 2021; 16:e0250726. [PMID: 33930051 PMCID: PMC8087099 DOI: 10.1371/journal.pone.0250726] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 04/12/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND We hypothesize that women undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis from appendiceal cancer will have a survival advantage compared to men. METHODS The National Cancer Database (NCDB) public user file (2004-2014) was used to select patients with PC undergoing CRS and HIPEC from appendiceal cancer. Univariate and multivariable analyses were performed. RESULTS 1,190 patients with PC from appendiceal cancer underwent HIPEC and CRS. OS was significantly longer for women than for men, with mean and median OS being 73.8 months and 98.2 months for women vs 58.7 months and 82.5 months for men, respectively (p = 0.0032). On multivariable analysis, male sex (HR: 1.444, 95% CI: 1.141-1.827, p = 0.0022) and increasing age (HR: 1.017, 95% CI: 1.006-1.027, p = 0.0017) were both found to be independent risk factors for worse OS. CONCLUSION Women undergoing CRS and HIPEC for PC from appendiceal origin live longer than men undergoing the same treatment. Increasing age was also found to be independent risk factors for worse survival.
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Affiliation(s)
- Noah S. Rozich
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States of America
| | - Samara E. Lewis
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States of America
| | - Sixia Chen
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States of America
| | - Kenneth E. Stewart
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States of America
| | - Michael B. Stout
- Department of Nutritional Sciences, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States of America
| | - William C. Dooley
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States of America
| | - Laura E. Fischer
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States of America
| | - Katherine T. Morris
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States of America
- * E-mail:
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18
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Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Surface Malignancies: Learning Curve Based on Surgical and Oncological Outcomes. Cancers (Basel) 2020; 12:cancers12092387. [PMID: 32842535 PMCID: PMC7565601 DOI: 10.3390/cancers12092387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/17/2020] [Accepted: 08/21/2020] [Indexed: 02/07/2023] Open
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19
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Foster JM, Patel A, Zhang C, Shostrom V, Brown K, Cushman-Vokoun AM. Investigating the utility of extended mutation analysis in gastrointestinal peritoneal metastasis. J Surg Oncol 2020; 122:1106-1113. [PMID: 32662065 DOI: 10.1002/jso.26114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 06/28/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVES Outcomes for gastrointestinal peritoneal metastases (GI-PM) are worse compared to systemic metastases, with a paucity of data exploring extended mutation profiling. An exploratory mutation analysis in GI-PMs was performed as a "proof of concept" of potential predictive values of profiling in GI-PM and rates of actionable mutations. METHODS The study included 40 GI-PM patients: 14 low-grade mucinous carcinoma peritonei and 26 HG-PM (12 colons, 10 appendix, 4 small bowels). Demographics, histologies, peritoneal cancer indexes, cytoreduction scores, and survival data were collected. NGS 50-gene mutation profiling was performed on 38 specimens. The association of mutations with survival was evaluated in high-grade PM. RESULTS KRAS, TP53, and SMAD4 mutations were observed in 61%, 29%, and 8% of cases across all tumor histologies. In 66% cases >1 mutations occurred, associated with decreased survival in HG-PM: 32 vs 73 months, P = .03. TP53 or SMAD4 mutations were associated with decreased survival in HG-PM: 22 vs 48 months, P = .02. Actionable mutations were detected in 70%. CONCLUSION Actionable mutations were detected at high rates. GI-PMs have similar mutational profiles and TP53, SMAD4, and/or >1 mutation were associate with decreased survival in HG-PM. This data supports the concept of the extended mutation profiling utility in GI-PM warranting further investigation.
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Affiliation(s)
- Jason M Foster
- Department of Surgery, Division of Surgical Oncology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Asish Patel
- Department of Surgery, Division of Surgical Oncology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Chunmeng Zhang
- Department of Surgery, Division of Surgical Oncology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Valerie Shostrom
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, Nebraska
| | - Krista Brown
- Department of Surgery, Division of Surgical Oncology, University of Nebraska Medical Center, Omaha, Nebraska
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20
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Chen JC, Beal EW, Hays J, Pawlik TM, Abdel-Misih S, Cloyd JM. Outcomes of neoadjuvant chemotherapy before CRS-HIPEC for patients with appendiceal cancer. J Surg Oncol 2020; 122:388-398. [PMID: 32383206 DOI: 10.1002/jso.25967] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/07/2020] [Accepted: 04/24/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Cytoreductive surgery (CRS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC) is indicated for patients with peritoneal dissemination of appendiceal cancer. The role of neoadjuvant chemotherapy (NAC) before CRS-HIPEC remains controversial. METHODS A retrospective review of adult patients who underwent CRS ± HIPEC for metastatic appendiceal cancer between 2000-2017 was performed. Patients who received NAC followed by surgery were compared with those who underwent surgery first (SF) with and without 1:1 propensity score matching (PSM). RESULTS Among 803 patients with appendiceal cancer who underwent CRS ± HIPEC, 225 (28%) received NAC, and 578 (72%) underwent SF. After PSM (n = 186), median overall survival (OS) did not differ (NAC: 40 vs SF: 56 months; P = .210) but recurrence-free survival (RFS) was worse among patients who received NAC (14 vs 22 months; P = .007). NAC was independently associated with worse OS (hazards ratio [HR], 1.81; 95% confidence interval [CI], 1.03-3.18) and RFS (HR, 1.93; 95% CI, 1.25-2.99). CONCLUSION In this multi-institutional retrospective analysis of patients with peritoneal dissemination from appendiceal cancer, the use of NAC before CRS-HIPEC was associated with worse OS and RFS even after PSM and multivariable regression. Immediate surgery should be considered for patients with disease amenable to complete cytoreduction.
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Affiliation(s)
- J C Chen
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Eliza W Beal
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - John Hays
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sherif Abdel-Misih
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jordan M Cloyd
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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21
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Su J, Jin G, Votanopoulos KI, Craddock L, Shen P, Chou JW, Qasem S, O'Neill SS, Perry KC, Miller LD, Levine EA. Prognostic Molecular Classification of Appendiceal Mucinous Neoplasms Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2020; 27:1439-1447. [PMID: 31980985 PMCID: PMC7147286 DOI: 10.1245/s10434-020-08210-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Appendiceal mucinous neoplasm (AMN) with peritoneal metastasis is a rare but deadly disease with few prognostic or therapy-predictive biomarkers to guide treatment decisions. Here, we investigated the prognostic and biological attributes of gene expression-based AMN molecular subtypes. METHODS AMN specimens (n = 138) derived from a population-based subseries of patients treated at our institution with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) between 05/2000 and 05/2013 were analyzed for gene expression using a custom-designed NanoString 148-gene panel. Signed non-negative matrix factorization (sNMF) was used to define a gene signature capable of delineating robustly-classified AMN molecular subtypes. The sNMF class assignments were evaluated by topology learning, reverse-graph embedding and cross-cohort performance analysis. RESULTS Three molecular subtypes of AMN were discerned by the expression patterns of 17 genes with roles in cancer progression or anti-tumor immunity. Tumor subtype assignments were confirmed by topology learning. AMN subtypes were termed immune-enriched (IE), oncogene-enriched (OE) and mixed (M) as evidenced by their gene expression patterns, and exhibited significantly different post-treatment survival outcomes. Genes with specialized immune functions, including markers of T-cells, natural killer cells, B-cells, and cytolytic activity showed increased expression in the low-risk IE subtype, while genes implicated in the promotion of cancer growth and progression were more highly expressed in the high-risk OE subtype. In multivariate analysis, the subtypes demonstrated independent prediction power for post-treatment survival. CONCLUSIONS Our findings suggest a greater role for the immune system in AMN than previously recognized. AMN subtypes may have clinical utility for predicting CRS/HIPEC treatment outcomes.
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Affiliation(s)
- Jing Su
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Guangxu Jin
- Wake Forest Baptist Comprehensive Cancer Center, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Konstantinos I Votanopoulos
- Surgical Oncology Service, Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Lou Craddock
- Wake Forest Baptist Comprehensive Cancer Center, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Perry Shen
- Surgical Oncology Service, Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jeff W Chou
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Shadi Qasem
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Stacey S O'Neill
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kathleen Cummins Perry
- Surgical Oncology Service, Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Lance D Miller
- Wake Forest Baptist Comprehensive Cancer Center, Wake Forest School of Medicine, Winston-Salem, NC, USA.
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - Edward A Levine
- Surgical Oncology Service, Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA.
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22
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Beal EW, Ahmed A, Grotz T, Leiting J, Fournier KF, Lee AJ, Dineen S, Dessureault S, Baumgartner JM, Veerapong J, Clarke C, Strong E, Maithel SK, Zaidi MY, Patel S, Dhar V, Hendrix R, Lambert L, Johnston F, Fackche N, Raoof M, LaRocca C, Ronnekleiv-Kelly S, Pokrzywa C, Pawlik TM, Abdel-Misih S, Cloyd JM. Trends in the indications for and short-term outcomes of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Am J Surg 2020; 219:478-483. [DOI: 10.1016/j.amjsurg.2019.09.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 09/13/2019] [Accepted: 09/16/2019] [Indexed: 11/25/2022]
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23
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Moaven O, Votanopoulos KI, Shen P, Mansfield P, Bartlett DL, Russell G, McQuellon R, Stewart JH, Levine EA. Health-Related Quality of Life After Cytoreductive Surgery/HIPEC for Mucinous Appendiceal Cancer: Results of a Multicenter Randomized Trial Comparing Oxaliplatin and Mitomycin. Ann Surg Oncol 2019; 27:772-780. [PMID: 31720933 DOI: 10.1245/s10434-019-08064-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND This study evaluated health-related quality of life (HRQOL) using patient-reported outcomes in subjects with mucinous appendiceal neoplasms who underwent cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) as part of a randomized trial comparing mitomycin with oxaliplatin. METHODS In this prospective multicenter study, 121 mucinous appendiceal cancer patients, with evidence of peritoneal dissemination who underwent CRS, were randomized to receive mitomycin (divided 40 mg) or oxaliplatin (200 mg/m2) for HIPEC. The Functional Assessment of Cancer Therapy Neurotoxicity (FACT-G/NTX) questionnaire was utilized to assess HRQOL. The Trial Outcome Index (TOI) is a summary index responsive to changes in physical/functional outcomes. Repeated measures mixed models with an unstructured variance matrix were applied to assess changes in HRQOL longitudinally. RESULTS Baseline questionnaire compliance was 95.9%. Baseline physical well-being (PWB) was independently associated with overall survival (hazard ratio 0.79, 95% confidence interval 0.66-0.96; p = 0.017). The TOI was significantly lower in the mitomycin group compared with the oxaliplatin arm at 12 weeks (p = 0.044; score difference 6.35) and 24 weeks after surgery (p = 0.049; score difference 5.61). At 12 weeks after surgery, declines from baseline were significant in the TOI (p = 0.004; score decline 8.99), PWB (p < 0.001; score decline 2.83), and FWB (p < 0.001; score decline 3.42) in the mitomycin group but not the oxaliplatin group. CONCLUSIONS Compared with mitomycin, HIPEC perfusion with oxaliplatin results in significantly better physical and functional outcomes. With similar survival outcomes and complication rates, oxaliplatin should be considered as the chemoperfusion agent of choice in mucinous appendiceal cancer patients undergoing CRS/HIPEC.
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Affiliation(s)
- Omeed Moaven
- Department of Surgery, Wake Forest University, Winston Salem, NC, USA
| | | | - Perry Shen
- Department of Surgery, Wake Forest University, Winston Salem, NC, USA
| | - Paul Mansfield
- Department of Surgical Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - David L Bartlett
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Greg Russell
- Department of Surgery, Wake Forest University, Winston Salem, NC, USA
| | - Richard McQuellon
- Department of Surgery, Wake Forest University, Winston Salem, NC, USA
| | - John H Stewart
- Department of Surgery, University of Illinois, Chicago, IL, USA
| | - Edward A Levine
- Department of Surgery, Wake Forest University, Winston Salem, NC, USA. .,Section of Surgical Oncology, Department of General Surgery, Wake Forest Baptist Health, Winston Salem, NC, USA.
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24
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Webb C, Day R, Velazco CS, Pockaj BA, Gray RJ, Stucky CC, Young-Fadok T, Wasif N. Implementation of an Enhanced Recovery After Surgery (ERAS) Program is Associated with Improved Outcomes in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2019; 27:303-312. [PMID: 31605328 DOI: 10.1245/s10434-019-07900-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has been associated with increased postoperative complications and a prolonged length of stay (LOS). We report on our experience following implementation of an Enhanced Recovery After Surgery (ERAS) program for CRS and HIPEC. METHODS Patients were divided into pre- and post-ERAS groups. Modifications in the ERAS group included routine use of transversus abdominis plane blocks, intra- and postoperative fluid restriction, and minimizing the use of narcotics, drains, and nasogastric tubes. RESULTS Of a total of 130 procedures, 49 (38%) were in the pre-ERAS group and 81 (62%) were in the ERAS group. Mean LOS was reduced from 10.3 ± 8.9 days to 6.9 ± 5.0 days (p = 0.007) and the rate of grade III/IV complications was reduced from 24 to 15% (p = 0.243) following ERAS implementation. The ERAS group received less intravenous fluid during hospitalization (19.2 ± 18.7 L vs. 32.8 ± 32.5 L, p = 0.003) and used less opioids than the pre-ERAS group (median of 159.7 mg of oral morphine equivalents vs. 272.6 mg). There were no significant changes in the rates of 30-day readmission or acute kidney injury between the two groups (p = non-significant). On multivariable analyses, ERAS was significantly associated with a reduction in LOS (- 2.89 days, 95% CI - 4.84 to - 0.94) and complication rates (odds ratio 0.22, 95% CI 0.08-0.57). CONCLUSIONS Implementation of an ERAS program for CRS and HIPEC is associated with a reduction in overall intravenous fluids, postoperative narcotic use, complication rates, and LOS.
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Affiliation(s)
- Christopher Webb
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Ryan Day
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Cristine S Velazco
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Barbara A Pockaj
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Richard J Gray
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Chee-Chee Stucky
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Tonia Young-Fadok
- Department of Surgery, Division of Colorectal Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Nabil Wasif
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA.
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25
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Systemic chemotherapy before cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) in patients with high-grade mucinous carcinoma peritonei of appendiceal origin. Eur J Surg Oncol 2019; 45:1598-1606. [PMID: 31109821 DOI: 10.1016/j.ejso.2019.05.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 05/08/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The role of systemic chemotherapy (SC) before cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) in appendiceal high-grade mucinous carcinoma peritonei (HGMCP) is controversial. We analyzed the effect of SC prior to CRS/HIPEC in HGMCP. METHODS A prospective database of CRS/HIPEC procedures for HGMCP without signet ring cells and with signet ring cells (HGMCP-S) from 1998 to 2017 was reviewed. Exclusion criteria was prior surgery >5 regions or >2 regimens of prior SC. Perioperative variables were analyzed. RESULTS There were 140 HGMCP/HGMCP-S identified: 64 with prior SC (preSC) and 76 without (noSC). Groups were balanced for lymph node status, complete cytoreduction rate, disease burden, complications, and postoperative SC. PreSC had more HGMCP-S, moderately/poorly differentiated histology, and longer time-to-surgery (median: 6 vs 2 months, p < 0.001). Median overall survival (mOS) was 40 vs 86 and median progression-free survival (mPFS) was 19 vs 43 months for preSC vs noSC, respectively (p = 0.006 and p = 0.007). In HGMCP-S subanalysis, mOS was 25 vs 39 and mPFS 16 vs 29 months for preSC vs noSC, respectively (p = 0.188 and p = 0.063). In moderately/poorly differentiated histology subanalysis, mOS was 38 vs 56 and mPFS 18 vs 29 months in preSC vs noSC, respectively (p = 0.199 and 0.082). Prior SC was not linked to improved OS or PFS in non-signet ring HGMCP or well-differentiated histology subanalysis. CONCLUSION Prior SC was not associated with less disease burden, better cytoreduction rates, or improved clinical outcomes in HGMCP, regardless of histopathologic subtype. Traditional SC agents may not be effective in HGMCP in the neoadjuvant setting.
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Munoz-Zuluaga C, King MC, Sardi A, Ledakis P, Sittig M, Nieroda C, MacDonald R, Gushchin V. Selection and Characteristics of Patients with Peritoneal Dissemination from Appendiceal Cancer with Exceptional/Poor Survival After CRS/HIPEC. Ann Surg Oncol 2019; 26:2268-2275. [PMID: 31041628 DOI: 10.1245/s10434-019-07374-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Survival in peritoneal dissemination from appendiceal cancer after complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) varies within each histopathologic subtype. Analyzing patients with unique responses may uncover the mechanisms behind their extreme outcomes. We proposed a method to identify retrospectively and to characterize patients who responded exceptionally well or very poorly within each histopathologic subtype. METHODS Retrospective review of patients with low-grade mucinous carcinoma peritonei (LGMCP), high-grade MCP (HGMCP), and HGMCP with signet ring cells (HGMCP-S) with complete CRS/HIPEC (CC-0/1) was performed. Patients were divided by recurrence status. Median follow-up was calculated for each. Exceptional responders (ExR) were defined as alive without recurrence after median follow-up of the nonrecurrent group. Poor responders (PoR) were defined as disease recurrence before median follow-up of the recurrent group. Perioperative characteristics were analyzed. RESULTS LGMCP, HGMCP, and HGMCP-S had 48 (41%), 19 (23%), and 7 (14%) ExR and 11 (10%), 20 (24%), and 20 (39%) PoR, respectively. All ExR had lower median PCI (26 vs. 36 [p = 0.004]; 13 vs. 33.5 [p < 0.001]; 3 vs. 29.5 [p = 0.001]). Fewer LGMCP and HGMCP ExR had abnormal tumor markers (36% vs. 90% [p = 0.003]; 22% vs. 74% [p = 0.003]). More HGMCP and HGMCP-S ExR had CC-0 (vs. CC-1) cytoreductions (84% vs. 50%, p = 0.041; 100% vs. 40%, p = 0.008). CONCLUSIONS Stratifying patients by recurrence status and follow-up time successfully selects ExR and PoR within each histopathologic subtype. Perioperative characteristics of ExR versus PoR differ across histopathologic subtypes, except for disease burden. Genetic analysis may further elucidate differences and aid in the development of novel targeted therapies.
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Affiliation(s)
| | - Mary Caitlin King
- The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA
| | - Armando Sardi
- The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA.
| | - Panayotis Ledakis
- The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA
| | - Michelle Sittig
- The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA
| | - Carol Nieroda
- The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA
| | - Ryan MacDonald
- Center for Clinical Excellence, Mercy Medical Center, Baltimore, MD, USA
| | - Vadim Gushchin
- The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA
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Hendrix RJ, Damle A, Williams C, Harris A, Spanakis S, Lambert DH, Lambert LA. Restrictive Intraoperative Fluid Therapy is Associated with Decreased Morbidity and Length of Stay Following Hyperthermic Intraperitoneal Chemoperfusion. Ann Surg Oncol 2018; 26:490-496. [PMID: 30515670 DOI: 10.1245/s10434-018-07092-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Indexed: 01/27/2023]
Abstract
BACKGROUND Recent data have demonstrated multiple benefits of intra- and postoperative fluid restriction in major abdominal surgery; however, data regarding the outcomes of fluid restriction in cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion (CRS/HIPEC) are limited. This study evaluates the safety and short-term clinical outcomes of restricted intraoperative fluid therapy in CRS/HIPEC. METHODS This was a single-institution, retrospective review of all CRS/HIPEC procedures performed at the University of Massachusetts Medical School between January 2009 and July 2017. Recorded variables included demographics, intraoperative factors, 60-day postoperative complications, and length of stay (LOS). Outcomes based on the use of intraoperative permissive fluid therapy (PFT) versus restrictive fluid therapy (RFT) were compared. RESULTS Overall, 169 CRS/HIPEC cases were performed during the study period; 84 were managed with PFT and 85 were managed with RFT. No significant differences were identified in patient demographics. There was a decrease in intraoperative administration of crystalloid (8.0 vs. 4.4 L, p < 0.01), colloid (900 vs. 300 mL, p < 0.01), and blood transfusion (0.26 vs. 0.04 units, p < 0.01) in the RFT cohort. LOS was reduced from 11.5 to 9.7 days (p < 0.01) and the incidence of any 60-day complication decreased from 45 to 28% (p = 0.02) in the RFT group. The overall 90-day mortality rate was 0.6% (n = 1). Adjusted logistic regression demonstrated the odds of having a Clavien-Dindo grade III or higher complication was 0.31 (95% confidence interval 0.10-0.95) with RFT. CONCLUSION Intraoperative RFT with standard anesthesia monitoring devices can be safely used in CRS/HIPEC and is associated with a decreased LOS and decreased rate of postoperative complications.
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Affiliation(s)
- Ryan J Hendrix
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Aneel Damle
- Section of Colon and Rectal Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Chloe Williams
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Ariana Harris
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Spiro Spanakis
- Division of Perioperative Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Donald H Lambert
- Department of Anesthesiology, Boston University School of Medicine, Boston, MA, USA
| | - Laura A Lambert
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA. .,Peritoneal Surface Malignancy Program, Section of Surgical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
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28
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Votanopoulos KI, Shen P, Skardal A, Levine EA. Peritoneal Metastases from Appendiceal Cancer. Surg Oncol Clin N Am 2018; 27:551-561. [PMID: 29935689 DOI: 10.1016/j.soc.2018.02.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
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.
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Affiliation(s)
- Konstantinos I Votanopoulos
- Surgical Oncology Service, Department of General Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA.
| | - Perry Shen
- Surgical Oncology Service, Department of General Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
| | - Aleksander Skardal
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - Edward A Levine
- Surgical Oncology Service, Department of General Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
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29
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Votanopoulos KI, Mazzocchi A, Sivakumar H, Forsythe S, Aleman J, Levine EA, Skardal A. Appendiceal Cancer Patient-Specific Tumor Organoid Model for Predicting Chemotherapy Efficacy Prior to Initiation of Treatment: A Feasibility Study. Ann Surg Oncol 2018; 26:139-147. [PMID: 30414038 DOI: 10.1245/s10434-018-7008-2] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Indexed: 12/11/2022]
Abstract
INTRODUCTION We have hypothesized that biofabrication of appendiceal tumor organoids allows for a more personalized clinical approach and facilitates research in a rare disease. METHODS Appendiceal cancer specimens obtained during cytoreduction with hyperthermic intraperitoneal chemotherapy procedures (CRS/HIPEC) were dissociated and incorporated into an extracellular matrix-based hydrogel system as three-dimensional (3D), patient-specific tumor organoids. Cells were not sorted, preserving tumor heterogeneity, including stroma and immune cell components. Following establishment of organoid sets, chemotherapy drugs were screened in parallel. Live/dead staining and quantitative metabolism assays recorded which chemotherapies were most effective in killing cancer cells for a specific patient. Maintenance of cancer phenotypes were confirmed by using immunohistochemistry. RESULTS Biospecimens from 12 patients were applied for organoid development between November 2016 and May 2018. Successful establishment rate of viable organoid sets was 75% (9/12). Average time from organoid development to chemotherapy testing was 7 days. These tumors included three high-grade appendiceal (HGA) and nine low-grade appendiceal (LGA) primaries obtained from sites of peritoneal metastasis. All tumor organoids were tested with chemotherapeutic agents exhibited responses that were either similar to the patient response or within the variability of the expected clinical response. More specifically, HGA tumor organoids derived from different patients demonstrated variable chemotherapy tumor-killing responses, whereas LGA organoids tested with the same regimens showed no response to chemotherapy. One LGA set of organoids was immune-enhanced with cells from a patient-matched lymph node to demonstrate feasibility of a symbiotic 3D reconstruction of a patient matched tumor and immune system component. CONCLUSIONS Development of 3D appendiceal tumor organoids is feasible even in low cellularity LGA tumors, allowing for individual patient tumors to remain viable for research and personalized drug screening.
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Affiliation(s)
- Konstantinos I Votanopoulos
- Department of Surgery - Oncology, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA. .,Comprehensive Cancer Center at Wake Forest Baptist Medical, Winston-Salem, NC, USA.
| | - Andrea Mazzocchi
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.,Virginia Tech-Wake Forest School of Biomedical Engineering and Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Hemamylammal Sivakumar
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Steven Forsythe
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.,Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Julio Aleman
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Edward A Levine
- Department of Surgery - Oncology, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA.,Comprehensive Cancer Center at Wake Forest Baptist Medical, Winston-Salem, NC, USA
| | - Aleksander Skardal
- Comprehensive Cancer Center at Wake Forest Baptist Medical, Winston-Salem, NC, USA. .,Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA. .,Virginia Tech-Wake Forest School of Biomedical Engineering and Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA. .,Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
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30
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Babcock B, Jabo B, Selleck M, Reeves M, Garberoglio C, Namm J, Kazanjian K, Senthil M. Factors Predictive of Outcomes after Cytoreductive Surgery and Heated Intraperitoneal Chemotherapy for Colon and Appendiceal Carcinomatosis: A Single-Institution Experience. Am Surg 2018. [DOI: 10.1177/000313481808401007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC), although considered an acceptable treatment option in the management of selected patients with colon and appendiceal peritoneal carcinomatosis (PC), concerns about morbidity have limited its acceptance. Our objective was to evaluate the short- and long-term outcomes of CRS/HIPEC for appendix and colon PC performed at our institution and to elucidate factors predictive of patient outcomes. All patients who underwent CRS/HIPEC for appendix or colon PC from 2011 to 2017 were identified from our institution's prospective database. Postoperative outcomes, overall survival, and recurrence-free survival were assessed. Of 125 patients who underwent CRS/HIPEC during the study period, 45 patients were eligible (appendix n = 26; colon n = 19). The median postoperative length of stay was nine days (5–28 days). Grade III/IV complications occurred in 4/45 (8.8%) patients. There were no postoperative mortalities. Median DFS and overall survival have not yet been reached, in both the colon and appendix groups. As of the study conclusion date, 37/45 (82.2%) patients were alive with or without disease. Lymph node status was predictive of recurrence in appendix PC. In our experience, CRS/HIPEC can be safely performed with acceptable short- and long-term outcomes. Lymph node status is an important predictor of recurrence.
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Affiliation(s)
- Blake Babcock
- Loma Linda University Cancer Center, Loma Linda, California
| | - Brice Jabo
- Loma Linda University Cancer Center, Loma Linda, California
| | | | - Mark Reeves
- Loma Linda University Cancer Center, Loma Linda, California
| | | | - Jukes Namm
- Loma Linda University Cancer Center, Loma Linda, California
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31
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Roses RE, Folkert IW, Krouse RS. Malignant Bowel Obstruction: Reappraising the Value of Surgery. Surg Oncol Clin N Am 2018; 27:705-715. [PMID: 30213414 DOI: 10.1016/j.soc.2018.05.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Urgent palliative surgery in the setting of advanced malignancy is associated with significant morbidity, mortality, and cost. Malignant bowel obstruction is the most frequent indication for such intervention. Traditional surgical dogma is often invoked to justify associated risks and cost, but little evidence exists to support surgical over nonsurgical approaches. Evolving evidence may provide more meaningful guidance for treatment selection.
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Affiliation(s)
- Robert E Roses
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein Pavilion, Philadelphia, PA 19104, USA.
| | - Ian W Folkert
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Maloney Building, Philadelphia, PA 19104, USA
| | - Robert S Krouse
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA 19104, USA
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32
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Kuncewitch M, Levine EA, Shen P, Votanopoulos KI. The Role of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Appendiceal Tumors and Colorectal Adenocarcinomas. Clin Colon Rectal Surg 2018; 31:288-294. [PMID: 30186050 DOI: 10.1055/s-0038-1642052] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Peritoneal surface disease (PSD) has historically been used interchangeably with the term peritoneal carcinomatosis (PC) and has a dismal natural history. A variety of malignant pathologies, including colorectal and appendiceal primary tumors, can disseminate throughout the peritoneal cavity, leading to bowel obstruction and death. In general, peritoneal spread from high-grade appendiceal and colorectal primaries has the potential of hepatic and distant spread and best classified as PC. Low-grade appendiceal tumors are better categorized as PSD, due to low cellularity, high mucin production, and lack of potential spread outside the peritoneal cavity. Growing international experience with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) over the past 30 years has presented a therapeutic option to patients with PSD from colorectal and appendiceal tumors that can provide significant disease control, as well as potential for previously unattainable long-term survival. The proliferation of HIPEC centers and ongoing prospective trials are helping to standardize HIPEC techniques and patient selection.
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Affiliation(s)
- Michael Kuncewitch
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Edward A Levine
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Perry Shen
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
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33
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Jacobson R, Sherman SK, Dahdaleh F, Turaga KK. Peritoneal Metastases in Colorectal Cancer. Ann Surg Oncol 2018; 25:2145-2151. [PMID: 29748885 DOI: 10.1245/s10434-018-6490-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Indexed: 12/30/2022]
Affiliation(s)
- Richard Jacobson
- Department of Surgery, University of Chicago, Chicago, IL, USA.,Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Scott K Sherman
- Department of Surgery, University of Chicago, Chicago, IL, USA
| | | | - Kiran K Turaga
- Department of Surgery, University of Chicago, Chicago, IL, USA.
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34
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Choudry HA, Pai RK. Management of Mucinous Appendiceal Tumors. Ann Surg Oncol 2018; 25:2135-2144. [DOI: 10.1245/s10434-018-6488-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Indexed: 12/12/2022]
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35
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Levine EA, Votanopoulos KI, Shen P, Russell G, Fenstermaker J, Mansfield P, Bartlett D, Stewart JH. A Multicenter Randomized Trial to Evaluate Hematologic Toxicities after Hyperthermic Intraperitoneal Chemotherapy with Oxaliplatin or Mitomycin in Patients with Appendiceal Tumors. J Am Coll Surg 2018; 226:434-443. [PMID: 29331663 DOI: 10.1016/j.jamcollsurg.2017.12.027] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 12/14/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND Appendiceal cancer is a rare disease that has proven difficult to study in prospective trials. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) is an established therapy for peritoneal dissemination from appendiceal cancer. The optimal chemotherapeutic agent to use in the HIPEC is not clear. Mitomycin has long been used, however, our previous phase I experience and European retrospective studies suggest oxaliplatin as an alternative. Therefore, we initiated a multicenter randomized trial to compare mitomycin with oxaliplatin HIPEC for appendiceal cancer. STUDY DESIGN Patients with mucinous appendiceal neoplasms with evidence of peritoneal dissemination underwent cytoreductive surgery and HIPEC using a closed technique for 120 minutes. Patients were randomized intraoperatively to HIPEC using mitomycin (40 mg) or oxaliplatin (200 mg/M2). Follow-up included daily blood counts and toxicity assessments. RESULTS One hundred and twenty-one analytic patients were accrued to the trial during 6 years at 3 sites. The patients were 57% female, with a mean age of 55.3 years (range 22 to 82 years). The disease was low grade in 77% and high grade in 23%. There were no significant differences in hemoglobin or platelet counts. The WBC was significantly lower in the mitomycin group between postoperative days 5 and 10. Overall and disease-free survival rates at 3 years were similar at 83.7% and 66.8% for mitomycin and 86.9% and 64.8% for oxaliplatin. CONCLUSIONS This represents the first completed prospective randomized trial for cancer of the appendix, and shows that multicenter trials for this disease are feasible. Both mitomycin and oxaliplatin are associated with minor hematologic toxicity. However, mitomycin has slightly higher hematologic toxicity and lower quality of life than oxaliplatin in HIPEC. Consequently, oxaliplatin might be preferred in patients with leukopenia and mitomycin preferred in patients with thrombocytopenia due to earlier chemotherapy.
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Affiliation(s)
- Edward A Levine
- Section of Surgical Oncology, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC.
| | | | - Perry Shen
- Section of Surgical Oncology, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC
| | - Greg Russell
- Department of Biostatistical Sciences, Wake Forest Baptist Health, Winston-Salem, NC
| | - Joyce Fenstermaker
- Section of Surgical Oncology, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC
| | | | | | - John H Stewart
- Section of Surgical Oncology, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC
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Votanopoulos KI, Bartlett D, Moran B, Haroon CM, Russell G, Pingpank JF, Ramalingam L, Kandiah C, Chouliaras K, Shen P, Levine EA. PCI is Not Predictive of Survival After Complete CRS/HIPEC in Peritoneal Dissemination from High-Grade Appendiceal Primaries. Ann Surg Oncol 2017; 25:674-678. [PMID: 29288288 DOI: 10.1245/s10434-017-6315-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is a treatment option in patients with carcinomatosis from high-grade appendiceal (HGA) primaries. It is unknown if there is a Peritoneal Carcinomatosis Index (PCI) upper limit above which a complete CRS/HIPEC does not assure long-term survival. METHODS Retrospective analysis from three centers was performed. The PCI was used to grade volume of of disease. Survival in relation to PCI was studied on patients with complete cytoreduction. RESULTS Overall, 521 HGA patients underwent CRS/HIPEC from 1993 to 2015, with complete CRS being achieved in 50% (260/622). Mean PCI was 14.8 (standard deviation 8.7, range 0-36). Median survival for the complete CRS cohort was 6.1 years, while 5- and 10-year survival was 51.7% (standard error [SE] 4.6) and 36.1% (SE 6.3), respectively. Arbitrary cut-off PCI limits with 5-point splits (p = 0.63) were not predictive of a detrimental effect on survival as long as a complete CRS was achieved. A linear effect of the PCI on survival (p = 0.62) was not observed, and single-point PCI cohort splits within a PCI range of < 5 to > 10 were not predictive of survival for complete CRS patients. The PCI correlated with the ability to achieve a complete CRS, with a mean PCI of 14.7 (8.7) for completeness of cytoreduction (CC)0, 22.3 (7.8) for CC1 and 26.1 (9.5) for CC2/3 resections (p = 0.0001, hazard ratio 1.12, 95% confidence interval 1.09), with an HR of 1.15 for each 1-unit increase in the PCI score. Only 21% of the cohort achieved a complete CRS with a PCI ≥ 21. CONCLUSIONS The PCI correlates with the ability to achieve a complete CRS in carcinomatosis from HGA. PCI is not associated with survival as long as a complete CRS can be achieved.
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Affiliation(s)
| | - David Bartlett
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Brendan Moran
- Peritoneal Malignancy Institute, North Hampshire Hospital, Basingstoke, UK
| | - Choudry M Haroon
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Greg Russell
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - James F Pingpank
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Lekshmi Ramalingam
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Konstantinos Chouliaras
- Division of Surgical Oncology, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Perry Shen
- Division of Surgical Oncology, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Edward A Levine
- Division of Surgical Oncology, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA
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Scholer AJ, Oliver JB, Rosado J, Patel JS, Lynch LJ, Spiegler KM, Houck K, Chokshi RJ. Abdominal wall reconstruction after cytoreduction surgery-hyperthermic intraperitoneal chemotherapy. J Surg Res 2017; 221:266-274. [PMID: 29229138 DOI: 10.1016/j.jss.2017.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 06/08/2017] [Accepted: 08/01/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Cytoreduction surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) improve survival and decrease recurrence of peritoneal metastasis in a select population of patients. Abdominal wall resection is often needed to achieve complete CRS and the extent of abdominal wall resection may necessitate abdominal wall reconstruction (AWR). We sought to investigate if postoperative morbidity and mortality was increased in patients who underwent AWR with CRS-HIPEC (AWR group) compared to CRS-HIPEC without AWR (non-AWR group) and to identify if patient, tumor, and operative risk factors were associated with poor outcomes following AWR. We postulate that AWR is a safe and viable treatment option in appropriately selected patients with peritoneal disease. METHODS A retrospective chart review was conducted from 2012 to 2015. Demographics, comorbidities, intraoperative variables, and postoperative outcomes were analyzed and compared between the non-AWR group and the AWR group. RESULTS A total of 30 patients underwent CRS-HIPEC at our institution; 19 recruited in non-AWR group and 11 in the AWR arm. Median follow-up was 19.1 mo for the non-AWR group and 15.6 mo for AWR. Overall survival and complications were not significantly different between groups. Six patients in the non-AWR group and three patients in AWR group died during the follow-up period (32% versus 27%, P = 0.75). Grade III/IV Clavien-Dindo complications were similar in AWR compared to non-AWR group (64% versus 50%, P = 0.46) however estimated blood loss (1000 mL versus 450 mL, P = 0.01) and operative time (663 min versus 510 min, P = 0.02) were significantly increased in the AWR group. CONCLUSIONS The results of this study demonstrate that AWR is a safe and viable option and can improve wound closure and strength in select patient populations undergoing CRS-HIPEC. AWR is not associated with an increase in mortality or complication rate. Future studies will need larger sample sizes and randomization to identify patient and operative factors that increase morbidity with AWR and identify the ideal timing of AWR.
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Affiliation(s)
- Anthony J Scholer
- Department of Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey
| | - Joseph B Oliver
- Department of Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey
| | - Jesus Rosado
- Department of Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey
| | - Jimmy S Patel
- Department of Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey
| | - Lindsay J Lynch
- Department of Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey
| | - Kevin M Spiegler
- Department of Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey
| | - Karen Houck
- Department of Obstetrics and Gynecology, Rutgers University, New Jersey Medical School, Newark, New Jersey
| | - Ravi J Chokshi
- Department of Surgery, Section of Surgical Oncology, Rutgers University, New Jersey Medical School, Newark, New Jersey.
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Grotz TE, Overman MJ, Eng C, Raghav KP, Royal RE, Mansfield PF, Mann GN, Robinson KA, Beaty KA, Rafeeq S, Matamoros A, Taggart MW, Fournier KF. Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Moderately and Poorly Differentiated Appendiceal Adenocarcinoma: Survival Outcomes and Patient Selection. Ann Surg Oncol 2017; 24:2646-2654. [DOI: 10.1245/s10434-017-5938-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Indexed: 01/08/2023]
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Folkert IW, Roses RE. Value in palliative cancer surgery: A critical assessment. J Surg Oncol 2016; 114:311-5. [PMID: 27393738 DOI: 10.1002/jso.24303] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 04/22/2016] [Indexed: 12/11/2022]
Abstract
Emergency operations are associated with increased morbidity, mortality, and cost compared to elective operations. Palliative and emergent surgery for patients with advanced malignancies is associated with additional risk and remains controversial. Emergent or palliative interventions can be broadly categorized according to indication. Tumor related complications (bleeding, obstruction, or perforation) merit specific consideration, as do specific presentations such as pneumoperitoneum, pneumatosis intestinalis, or peritonitis from other causes that may arise during active therapy for malignancies. Although nonoperative, endoscopic, and interventional treatment modalities are frequently available, surgery remains the only effective therapy in selected situations such as small intestinal obstruction and tumor perforation. Selection of patients for surgery requires consideration of factors including overall prognosis, performance status, and patients' priorities. Selection and risk assessment tools underscore the limited capacity of patients' with higher risk features for durable recovery but do not supplant nuanced clinical judgment. J. Surg. Oncol. 2016;114:311-315. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Ian W Folkert
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert E Roses
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Tuvin D, Berger Y, Aycart SN, Shtilbans T, Hiotis S, Labow DM, Sarpel U. Prophylactic hyperthermic intraperitoneal chemotherapy in patients with epithelial appendiceal neoplasms. Int J Hyperthermia 2016; 32:311-5. [PMID: 27050712 DOI: 10.3109/02656736.2016.1152514] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background Prophylactic hyperthermic intraperitoneal chemotherapy (HIPEC) is a promising approach for preventing peritoneal carcinomatosis in high-risk patients. We report our initial experience with prophylactic HIPEC in a series of patients with appendiceal neoplasms. Methods We retrospectively reviewed our prospectively maintained database to identify patients who underwent HIPEC in the absence of peritoneal disease. Patients with previously documented peritoneal surface disease were excluded. Data regarding clinical, operative and pathological features were analysed. Results Out of 322 HIPEC procedures performed between March 2007and August 2015, we identified 16 patients who underwent surgery with prophylactic intent. Primary diagnoses included high-grade and low-grade appendiceal neoplasms. Most patients presented originally with appendiceal perforation; all patients underwent initial surgery during which the appendix or right colon were resected. Following a median time interval of 2.2 months, a second surgery performed at our institution consisted of completion of omentectomy, partial colectomy and oophorectomy, with administration of prophylactic HIPEC (using mitomycin C). A totally laparoscopic approach was attempted and achieved in 11 patients in whom the median duration of surgery, estimated intraoperative blood loss and length of hospitalisation were 251 min, 100 cm(3) and 4 days, respectively. There were no cases of major perioperative morbidity or mortality. Conclusions Prophylactic HIPEC for appendiceal neoplasms is feasible, safe and may be performed laparoscopically. Larger studies with long-term follow-up are needed to determine whether a survival benefit is associated with this treatment.
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Affiliation(s)
- Daniel Tuvin
- a Department of Surgery, Division of Surgical Oncology , Icahn School of Medicine at Mount Sinai , New York
| | - Yaniv Berger
- a Department of Surgery, Division of Surgical Oncology , Icahn School of Medicine at Mount Sinai , New York
| | - Samantha N Aycart
- a Department of Surgery, Division of Surgical Oncology , Icahn School of Medicine at Mount Sinai , New York
| | - Tatiana Shtilbans
- b Department of Pathology , Icahn School of Medicine at Mount Sinai , New York , USA
| | - Spiros Hiotis
- a Department of Surgery, Division of Surgical Oncology , Icahn School of Medicine at Mount Sinai , New York
| | - Daniel M Labow
- a Department of Surgery, Division of Surgical Oncology , Icahn School of Medicine at Mount Sinai , New York
| | - Umut Sarpel
- a Department of Surgery, Division of Surgical Oncology , Icahn School of Medicine at Mount Sinai , New York
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Spiliotis J, Argiriou E, Vafias E, Manou V, Vaos N, Datsis A, Efstathiou E. Re-admissions for delayed complications after cytoreductive surgery and HIPEC. Acta Chir Belg 2016; 116:96-100. [PMID: 27385296 DOI: 10.1080/00015458.2016.1165019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Peritoneal metastasis (PM) is currently treated with the complex procedure of cytoreductive surgery and hyperthermic intra-peritoneal chemotherapy (CRS + HIPEC). This procedure presents high morbidity and mortality rates, but they have only been examined in the immediate post-operative period. The aim of our study is to present, describe and analyze the post-operative events, secondary to a cytoreductive surgery and HIPEC procedure that occurs after the patients' discharge from the hospital. PATIENTS AND METHODS We examine retrospectively 219 patients who were discharged from our hospital from the initial 230 patients with PM, who were operated on from August 2005 to August 2015 and underwent CRS and HIPEC. Complications are investigated from the patient's discharge date until the 90th post-operative day, and are categorized with the Clavien-Dindo classification. RESULTS We identified 17 patients (7.8%) who developed late complications. No major differences in patient characteristics were identified between this group of 17 patients and the rest, apart from a slightly higher PCI (23.5 vs. 22.3). Mean length of stay at the re-admission was 11.7 days. 5 of the patients (29.4%) had to be re-operated on, whereas we found a mortality of 11.8% (2/17 patients). The most common complications involved abdominal abscesses (17.6%), ureteral strictures (17.6%) and enterocutaneous fistulae (17.6%). CONCLUSION Our study highlights the late complications following CRS plus HIPEC procedures, that occur after the patient's discharge from the hospital, an issue that has not been investigated thoroughly yet and may have serious impact on the post-operative quality of life. The role of adjuvant chemotherapy following CRS and HIPEC procedures in the onset of such complications appears to be important and needs further investigation.
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Grotz TE, Mansfield PF, Royal RE, Mann GN, Rafeeq S, Beaty KA, Overman MJ, Fournier KF. Intrathoracic Chemoperfusion Decreases Recurrences in Patients with Full-Thickness Diaphragm Involvement with Mucinous Appendiceal Adenocarcinoma. Ann Surg Oncol 2016; 23:2914-9. [PMID: 27027310 DOI: 10.1245/s10434-016-5209-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) is the preferred treatment for selected patients with mucinous appendiceal adenocarcinoma. Frequently, the hemidiaphragms are infiltrated with tumor, requiring partial diaphragm resection (DR) in order to obtain complete cytoreduction (CC-0). The clinical significance of diaphragmatic invasion and the optimum management to prevent transmission of disease from abdomen to chest is largely unknown. METHODS This was a retrospective review of 78 patients with mucinous appendiceal adenocarcinoma undergoing cytoreduction and partial DR at a single institution between 2010 and 2014. RESULTS Partial DR was necessary in 31 (39.7 %) patients in order to obtain CC-0. DR was not associated with increased morbidity or poor survival. Of the 31 patients who had a DR, 26 (83.9 %) were treated with thoracoabdominal chemoperfusion. The remaining five (16.1 %) patients had the diaphragm closed prior to HIPEC. Thoracoabdominal chemoperfusion was not associated with increased 30-day grade III/IV morbidity or respiratory complications. Overall, five (20 %) patients with a DR developed thoracic recurrence. There were two (8 %) thoracic recurrences in the 26 patients treated with thoracic chemoperfusion compared with three (60 %) in the five patients who had their diaphragm closed prior to HIPEC (p = 0.002). In univariate analysis histology, CC-0 and thoracoabdominal chemoperfusion were associated with thoracic disease-free survival; however, none of these were significant on multivariate analysis. CONCLUSION DR is not associated with increased morbidity and should be performed, if needed, to obtain a CC-0. Following DR, patients remain at significant risk of developing thoracic recurrence. Thoracoabdominal chemoperfusion reduces this risk without increasing morbidity.
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Affiliation(s)
- Travis E Grotz
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Paul F Mansfield
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Richard E Royal
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gary N Mann
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Safia Rafeeq
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Karen A Beaty
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael J Overman
- Department of Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keith F Fournier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Newton AD, Bartlett EK, Karakousis GC. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: a review of factors contributing to morbidity and mortality. J Gastrointest Oncol 2016; 7:99-111. [PMID: 26941988 DOI: 10.3978/j.issn.2078-6891.2015.100] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is associated with prolonged survival for appropriately selected patients with peritoneal dissemination of abdominal malignancies. CRS and HIPEC has been criticized for perceived high rates of morbidity and mortality. Morbidity and mortality rates of CRS and HIPEC, however, do not appear dissimilar to those of other large abdominal surgeries, particularly when relevant patient and operative factors are accounted for. The risk of morbidity and mortality following this surgery for a given individual can be predicted in part by a variety of patient and operative factors. While strong data are lacking, the limited data that exists on the matter suggests that the independent contribution of the heated intraperitoneal chemotherapy to CRS and HIPEC morbidity is relatively small. A more thorough understanding of the patient and operative factors associated with CRS and HIPEC morbidity and mortality, as well as the specific complications related to the intraperitoneal chemotherapy, can better inform clinicians in multidisciplinary teams and patients alike in the decision-making for this surgery.
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Affiliation(s)
- Andrew D Newton
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Edmund K Bartlett
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Giorgos C Karakousis
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Low RN. Preoperative and surveillance MR imaging of patients undergoing cytoreductive surgery and heated intraperitoneal chemotherapy. J Gastrointest Oncol 2016; 7:58-71. [PMID: 26941984 DOI: 10.3978/j.issn.2078-6891.2015.115] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
MR imaging provides considerable advantages for imaging patients with peritoneal tumor. Its inherently superior contrast resolution compared to CT allows MRI to more accurately depict small peritoneal tumors that are often missed on other imaging tests. Combining different contrast mechanisms including diffusion-weighted (DW) MRI and gadolinium-enhanced MRI provides a powerful tool for preoperative and surveillance imaging in patients being considered for cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC).
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Affiliation(s)
- Russell N Low
- Department of Radiology and Sharp and Children's MRI Center, Sharp Memorial Hospital, San Diego, CA 92123, USA
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Cummins KA, Russell GB, Votanopoulos KI, Shen P, Stewart JH, Levine EA. Peritoneal dissemination from high-grade appendiceal cancer treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). J Gastrointest Oncol 2016; 7:3-9. [PMID: 26941979 DOI: 10.3978/j.issn.2078-6891.2015.101] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have shown variability in survival outcomes when used to treat peritoneal surface disease (PSD) from appendiceal and colorectal cancers. The primary goal of this study was to examine outcomes for high-grade appendiceal (HGA) and high-grade colonic primaries after CRS-HIPEC to determine if a significant difference exists between the two groups. METHODS A retrospective analysis of patients with peritoneal dissemination from appendiceal and colonic primaries were identified in a prospectively maintained database of 1,223 CRS-HIPEC procedures performed between 1991 and 2015. Patient demographics, performance status resection status, tumor grade, nodal status, morbidity, mortality, and survival were reviewed with biopsy-proven PSD being classified according to primary site. Univariate and multivariate analyses were performed, and outcomes compared. RESULTS The study identified 171 CRS-HIPEC procedures for 165 patients: 110 (66.7%) for HGA and 55 (33.3%) for high-grade colonic lesions. Observed median disease-free survival (DFS) and overall survival (OS) for both groups were the same at14.4 and 18 months, respectively. Median survival according to resection status for R0/R1, R2a, and R2b/c were 36, 15.6, and 8.4 months (P<0.0001). Median OS for those who received preoperative chemotherapy versus those who did not were 14.4 and 20.4 months, respectively (P=0.01). For those who received preoperative chemotherapy, no difference was apparent in the DFS interval (P=0.34). Multivariate predictors of OS included resection status (P<0.0001) and lymph node involvement (P=0.0005). CONCLUSIONS Preoperative chemotherapy offered no clear DFS or OS benefit, for HGA or high-grade colon cancer patients. Complete cytoreduction offered the greatest survival benefit to both groups with a correlating drop in survival to resection status. Outcomes for high grade appendiceal cancer are remarkably similar to colon cancer.
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Affiliation(s)
- Kathleen A Cummins
- 1 Section of Surgical Oncology, Department of General Surgery, 2 Department of Biostatistical Sciences, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Gregory B Russell
- 1 Section of Surgical Oncology, Department of General Surgery, 2 Department of Biostatistical Sciences, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Konstantinos I Votanopoulos
- 1 Section of Surgical Oncology, Department of General Surgery, 2 Department of Biostatistical Sciences, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Perry Shen
- 1 Section of Surgical Oncology, Department of General Surgery, 2 Department of Biostatistical Sciences, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - John H Stewart
- 1 Section of Surgical Oncology, Department of General Surgery, 2 Department of Biostatistical Sciences, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Edward A Levine
- 1 Section of Surgical Oncology, Department of General Surgery, 2 Department of Biostatistical Sciences, Wake Forest Baptist Health, Winston-Salem, NC, USA
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Levine EA, Votanopoulos KI, Qasem SA, Philip J, Cummins KA, Chou JW, Ruiz J, D'Agostino R, Shen P, Miller LD. Prognostic Molecular Subtypes of Low-Grade Cancer of the Appendix. J Am Coll Surg 2015; 222:493-503. [PMID: 26821970 DOI: 10.1016/j.jamcollsurg.2015.12.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 12/10/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND Appendiceal cancer (AC) patients treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) often demonstrate an unpredictable variability in their survival outcomes. Biomarkers predictive of CRS/HIPEC efficacy could better guide treatment decisions. We hypothesized that variation in the transcriptional programming of AC tumors might distinguish molecular subtypes with differential outcomes after CRS/HIPEC. STUDY DESIGN Gene expression profiles of 2 AC cohorts were analyzed using Affymetrix whole-genome expression microarrays. Hierarchical clustering methods, Kaplan-Meier analysis, and Cox regression models were used to discover and validate prognostic molecular subtypes of AC. Gene set enrichment analysis was used to infer pathologic attributes of the molecular subtypes. RESULTS Unsupervised hierarchical clustering analysis of tumor expression profiles revealed a 139-gene cassette that distinguished 2 molecular subtypes (based on low vs high expression of the gene cassette) with statistically significant survival differences (disease-specific survival, p = 0.0075; progression-free survival, p = 0.0072). In a second AC cohort, the 139-gene cassette reproducibly partitioned tumors into subtypes with significant survival differences. Tumors showing high relative expression of the genes comprising the cassette associated with poor survival outcomes (disease-specific survival, p = 0.047; progression-free survival, p = 0.0079), and exhibited gene expression patterns enriched for oncogenic processes and pathways. The prognostic value of the molecular subtypes was specific for low-grade appendiceal tumors (disease-specific survival, p = 0.028; progression-free survival, p = 0.0016), and remained significant in the presence of conventional prognostic markers, including grade, surgical resection score, Eastern Cooperative Oncology Group status, and age. CONCLUSIONS The 139-gene cassette can have actionable clinical utility for identifying low-grade appendiceal tumor molecular subtypes predictive of therapeutic efficacy of CRS/HIPEC.
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Affiliation(s)
- Edward A Levine
- Surgical Oncology Service, Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC; Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC.
| | - Konstantinos I Votanopoulos
- Surgical Oncology Service, Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC; Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | - Shadi A Qasem
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC; Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | - John Philip
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Kathleen A Cummins
- Surgical Oncology Service, Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC; Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | - Jeff W Chou
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - Jimmy Ruiz
- Department of Medicine, Section on Hematology and Oncology, Wake Forest School of Medicine, Winston-Salem, NC; Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | - Ralph D'Agostino
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC; Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | - Perry Shen
- Surgical Oncology Service, Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC; Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | - Lance D Miller
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC; Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
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Mogal HD, Levine EA, Fino NF, Obiora C, Shen P, Stewart JH, Votanopoulos KI. Routine Admission to Intensive Care Unit After Cytoreductive Surgery and Heated Intraperitoneal Chemotherapy: Not Always a Requirement. Ann Surg Oncol 2015; 23:1486-95. [PMID: 26572753 DOI: 10.1245/s10434-015-4963-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND Routine postoperative intensive care unit (ICU) observation of patients undergoing cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) is driven by historically reported morbidity and mortality data. The validity of this practice and the criteria for ICU admission have not been elucidated. METHODS A prospectively maintained database of 1146 CRS/HIPEC procedures performed from December 1991 to 2014 was retrospectively analyzed. Patients with routine postoperative ICU admission were compared with patients sent directly to the surgical floor. To test the safety of non-ICU care practice, patients with less than 48 h ICU admission were compared with patients directly admitted to the floor. Demographics, primary tumor site, comorbidities, estimated blood loss (EBL), extent of CRS, Eastern Cooperative Oncology Group (ECOG) status, and overall survival were analyzed. RESULTS Complete data were available for 1064 CRS/HIPEC procedures, of which 244 cases (22.93 %) did not require ICU admission. Multivariate logistic regression identified age [odds ratio (OR) 1.024; p = 0.02], EBL (OR 1.002; p < 0.0001), number of resected organs (OR 1.308; p = 0.01) and ECOG > 2 (OR 6.387; p = 0.003) as predictive variables of postoperative ICU admission. The cohort directly admitted to the floor demonstrated less minor grade I/II morbidity (29 vs. 47 %; p < 0.0001) and similar grade III/IV major morbidity (16.5 vs. 13.4 %; p = 0.3) than the patients admitted to the ICU for less than 48 h. CONCLUSIONS ICU observation is not routinely required for all patients treated with CRS/HIPEC. Selective ICU admission based on ECOG status, nutritional status, age, EBL, and CRS extent is safe, with potential implications for hospitalization cost for these complex cases.
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Affiliation(s)
- Harveshp D Mogal
- Surgical Oncology Service, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Edward A Levine
- Surgical Oncology Service, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Nora F Fino
- Department of Biostatistical Sciences, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Chukwuemeka Obiora
- Surgical Oncology Service, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Perry Shen
- Surgical Oncology Service, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - John H Stewart
- Surgical Oncology Service, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Konstantinos I Votanopoulos
- Surgical Oncology Service, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA.
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Mogal HD, Levine EA, Russell G, Shen P, Stewart JH, Votanopoulos KI. Conditional Survival After Cytoreductive Surgery with Heated Intraperitoneal Chemotherapy for Low- and High-Grade Appendiceal Primaries. Ann Surg Oncol 2015; 23:534-8. [PMID: 26289808 DOI: 10.1245/s10434-015-4821-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Survival of patients after cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy for appendiceal neoplasms is projected by conventional overall survival (OS) curves that do not address the survival time a patient has already accrued. We sought to study the conditional survival (CS) after CRS, contingent on patients surviving a fixed duration of time after surgery. METHODS A retrospective analysis of 493 appendiceal cancer patients from a prospective database was performed. OS was calculated for patients who achieved a complete CRS. CS was estimated based on Kaplan-Meier curves to determine what the patient's long-term survival (3-, 5-, 7-, or 10-year) would be if they were alive at 1, 2, or 3 years from surgery. RESULTS OS at 5 and 10 years for 137 low-grade patients with complete resections was 83.3 and 74.2 %, respectively. For low-grade patients still alive at 3 years, 5- and 10-year CS was 93.4 and 83.2 %, respectively. For the 35 high-grade patients with complete CRS who survived to 3 years, CS at 10 years was 41.7 %, while their 10-year conventional OS was 24.6 %. CONCLUSIONS Conventional analysis underestimates OS due to unpredictable variations in tumor biology. When adjusted for time already elapsed since surgery, improvements in survival estimates are more pronounced with high-grade tumors. CS outcomes can be used in determining the optimal frequency of long-term follow-up of these patients.
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Affiliation(s)
- Harveshp D Mogal
- Division of Surgical Oncology, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA.
| | - Edward A Levine
- Division of Surgical Oncology, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Greg Russell
- Department of Biostatistics, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Perry Shen
- Division of Surgical Oncology, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - John H Stewart
- Division of Surgical Oncology, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Konstantinos I Votanopoulos
- Division of Surgical Oncology, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA.
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Randle RW, Griffith KF, Fino NF, Swett KR, Stewart JH, Shen P, Levine EA, Votanopoulos KI. Appendiceal goblet cell carcinomatosis treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. J Surg Res 2015; 196:229-34. [PMID: 25881787 DOI: 10.1016/j.jss.2015.03.051] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Revised: 03/09/2015] [Accepted: 03/19/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is a treatment commonly applied to peritoneal surface disease from low-grade mucinous tumors of the appendix. Some centers have extended this therapy to carcinomatosis from more aggressive malignancies. Therefore, we reviewed our experience with CRS/HIPEC for patients with goblet cell carcinomatosis. METHODS Patients with carcinomatosis from appendiceal primaries with goblet cell features were identified in a prospectively maintained database of 1198 CRS/HIPEC procedures performed between 1991 and 2014. Patient demographics, disease characteristics, morbidity, mortality, and survival were reviewed. RESULTS A total of 31 patients with carcinomatosis originating from appendiceal goblet cell tumors underwent CRS/HIPEC during the study period. Patients were generally young (mean age, 53 y) and otherwise healthy (84% without comorbidities) with good performance status (94% Eastern Cooperative Oncology Group 0 or 1). The mean number of visceral resections was 3.5, and complete cytoreduction of macroscopic disease was accomplished in 36%. Major 90-d morbidity and mortality rates were 38.7% and 9.7%, respectively. Median overall survival (OS) for all patients was 18.4 mo. Patients with negative nodes had better survival than those with positive nodes (median OS, 29.2 versus 10.2 mo), respectively (P = 0.002). Although complete cytoreduction was associated with longer median OS after CRS/HIPEC (R0/R1 28.6 versus R2 17.2 mo, P = 0.47), the observed difference did not reach statistical significance. CONCLUSIONS CRS/HIPEC may improve survival in patients with node negative goblet cell carcinomatosis when a complete cytoreduction is achieved. Patients with disease not amenable to complete cytoreduction should not be offered CRS/HIPEC.
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Affiliation(s)
- Reese W Randle
- Section of Surgical Oncology, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Kayla F Griffith
- Section of Surgical Oncology, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Nora F Fino
- Department of Biostatistics, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Katrina R Swett
- Department of Biostatistics, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - John H Stewart
- Section of Surgical Oncology, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Perry Shen
- Section of Surgical Oncology, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Edward A Levine
- Section of Surgical Oncology, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Konstantinos I Votanopoulos
- Section of Surgical Oncology, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina.
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