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Nikiforchin A, Sardi A, King MC, Baron E, Lopez-Ramirez F, Falla-Zuniga LF, Barakat P, Iugai S, Pawlikowski K, Nieroda C, Gushchin V. Patterns of Recurrence in Appendix Cancer After Complete Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2023; 30:7848-7857. [PMID: 37633853 DOI: 10.1245/s10434-023-14145-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/26/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND It is thought that low-grade (LG) appendiceal cancer (AC) demonstrates predominantly intraperitoneal recurrence (IPR) after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC), whereas high-grade (HG) tumors progress both intra- and extraperitoneally (EPR). However, evidence supporting this conception is lacking; therefore, we assessed recurrence in various AC histologies. METHODS A retrospective, cohort study was conducted by using a single-center database (1998-2022). Recurrence patterns (IPR, EPR, combined) were identified for LG, HG, high-grade with signet ring cells (SRC), and goblet cell carcinoma (GCC). RESULTS We included 432 complete (CC-0/1) CRS/HIPECs: 200 LG, 114 HG, 72 SRC, and 46 GCC. Median follow-up was 78 (95% confidence interval [CI] 70-86) months. Overall, 34% (n = 148) of patients recurred. IPR was the most common (LG 16%, HG 27%, SRC 36%, GCC 26%) with median time to recurrence (MTR) of 21 (IQR: 12-40) months. EPR (liver, lung, pleura, lymph nodes, or bones) occurred in LG 3%, HG 9%, SRC 22%, and GCC 7%. MTR was 11 (IQR: 4-16) months. Combined pattern occurred in LG 0%, HG 8%, SRC 7%, and GCC 0%. MTR was 13 (IQR: 7-18) months. Iterative surgery was performed in 53% IPR, 18% EPR, and 51% combined. Median post-recurrence survival was longer after IPR compared with EPR and combined recurrence: 36 (95% CI 25-47) versus 13 (95% CI 7-19) and 18 (95% CI 6-30) months (p < 0.01). CONCLUSIONS After complete CRS/HIPEC, IPR was the predominant pattern in all AC histologies and occurred later. Post-recurrence survival after IPR was longer. Knowing AC recurrence patterns can help to understand its biology and plan follow-up and post-relapse management.
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Affiliation(s)
- Andrei Nikiforchin
- Surgical Oncology, The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA
| | - Armando Sardi
- Surgical Oncology, The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA.
| | - Mary Caitlin King
- Surgical Oncology, The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA
| | - Ekaterina Baron
- Surgical Oncology, The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA
| | - Felipe Lopez-Ramirez
- Surgical Oncology, The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA
| | | | - Philipp Barakat
- Surgical Oncology, The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA
| | - Sergei Iugai
- Surgical Oncology, The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA
| | - Kathleen Pawlikowski
- Surgical Oncology, The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA
| | - Carol Nieroda
- Surgical Oncology, The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA
| | - Vadim Gushchin
- Surgical Oncology, The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA
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Current Trends in Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for Peritoneal Disease from Appendiceal and Colorectal Malignancies. J Clin Med 2022; 11:jcm11102840. [PMID: 35628966 PMCID: PMC9143396 DOI: 10.3390/jcm11102840] [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: 04/13/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 12/10/2022] Open
Abstract
Peritoneal carcinomatosis (PC) is a poor prognostic factor for all malignancies. This extent of metastatic disease progression remains difficult to treat with systemic therapies due to poor peritoneal vascularization resulting in limited drug delivery and penetration into tissues. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are surgical interventions that directly target peritoneal tumors and have improved outcomes for PC resulting from appendiceal and colorectal cancer (CRC). Despite these radical therapies, long-term survival remains infrequent, and recurrence is common. The reasons for these outcomes are multifactorial and signal the need for the continued development of novel therapeutics, techniques, and approaches to improve outcomes for these patients. Here, we review landmark historical studies that serve as the foundation for current recommendations, recent discoveries, clinical trials, active research, and areas of future interest in CRS/HIPEC to treat PC originating from appendiceal and colorectal malignancies.
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Lopez-Ramirez F, Gushchin V, Sittig M, King MC, Baron E, Nikiforchin A, Nieroda C, Sardi A. Iterative Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy for Recurrent Mucinous Adenocarcinoma of the Appendix. Ann Surg Oncol 2022; 29:3390-3401. [PMID: 35133518 DOI: 10.1245/s10434-021-11233-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 11/04/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Recurrence after cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for appendiceal tumors (AT) with mucinous carcinomatosis peritonei (MCP) is common. The evidence favoring iterative procedures (iCRS/HIPEC) is limited, and its benefit is not clear for all patients. METHODS Retrospective (1998-2020) cohorts of AT patients with MCP recurrence after the first CRS/HIPEC were analyzed. Outcomes were compared within tumor grades between iCRS/HIPEC patients and matched control patients without iCRS/HIPEC using propensity score matching (1:1). Post-recurrence survival (PRS) was measured from the date of recurrence after the first CRS/HIPEC to death or last contact. RESULTS Overall, 55 iCRS/HIPEC patients were identified: 36 low-grade (LGMCP) patients, 13 high-grade (HGMCP) patients, and 6 HGMCP patients with signet-ring features (HGMCP-S). Nine patients had a third CRS/HIPEC. The median peritoneal cancer index (PCI) scores were 33, 19 and 10, with CC-0/1 achieved for 94.4%, 78.2% and 88.9% of the patients after the first, second, and third CRS/HIPEC, respectively. No 90-day postoperative mortality occurred. The median progression-free survival from the first CRS/HIPEC was 19.7 months for the iCRS/HIPEC patients versus 14.2 months for the matched control patients (p = 0.43). The median PRS was 80.2 months for iCRS/HIPEC versus 36.2 for the control patients (p < 0.001). For the iCRS/HIPEC versus the matched control patients, the median PRS by tumor grade was 174.1 versus 51.9 (p < 0.001) for the LGMCP, 42.0 versus 12.4 (p = 0.02) for the HGMCP, and 15.4 versus 8.1 months (p = 0.61) for the HGMCP-S patients, respectively. CONCLUSIONS Selected low- and high-grade appendiceal cancer patients with MCP recurrence able to undergo iterative CRS/HIPEC procedures showed favorable outcomes and such patients should be considered for surgery when feasible. This survival benefit with iCRS/HIPEC is not evidenced in recurrent MCP with signet ring cell morphology.
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Affiliation(s)
- Felipe Lopez-Ramirez
- Department of Surgical Oncology, Mercy Medical Center, The Institute for Cancer Care, Baltimore, MD, USA
| | - Vadim Gushchin
- Department of Surgical Oncology, Mercy Medical Center, The Institute for Cancer Care, Baltimore, MD, USA
| | - Michelle Sittig
- Department of Surgical Oncology, Mercy Medical Center, The Institute for Cancer Care, Baltimore, MD, USA
| | - Mary Caitlin King
- Department of Surgical Oncology, Mercy Medical Center, The Institute for Cancer Care, Baltimore, MD, USA
| | - Ekaterina Baron
- Department of Surgical Oncology, Mercy Medical Center, The Institute for Cancer Care, Baltimore, MD, USA
| | - Andrei Nikiforchin
- Department of Surgical Oncology, Mercy Medical Center, The Institute for Cancer Care, Baltimore, MD, USA
| | - Carol Nieroda
- Department of Surgical Oncology, Mercy Medical Center, The Institute for Cancer Care, Baltimore, MD, USA
| | - Armando Sardi
- Department of Surgical Oncology, Mercy Medical Center, The Institute for Cancer Care, Baltimore, MD, USA.
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The Utility of Preoperative Tumor Markers in Peritoneal Carcinomatosis from Primary Appendiceal Adenocarcinoma: an Analysis from the US HIPEC Collaborative. J Gastrointest Surg 2021; 25:2908-2919. [PMID: 33634422 DOI: 10.1007/s11605-021-04953-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 01/31/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Prognostication based on preoperative clinical factors is lacking in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). This study aims to determine the value of preoperative tumor markers as predictors of progression-free survival (PFS) and overall survival (OS) for patients with peritoneal carcinomatosis from a primary mucinous adenocarcinoma of the appendix (MACA). METHODS We queried the United States HIPEC Collaborative, a database of patients with peritoneal carcinomatosis treated with CRS/HIPEC at twelve institutions between 2000 and 2017, identifying 409 patients with MACA. Multivariate analysis was used to identify independent predictors of disease progression. Subgroup analysis was conducted to evaluate the impact of tumor grade on the predictive value of tumor markers. RESULTS CA19-9 [HR 2.44, CI 1.2-3.4] emerged as an independent predictor of PFS while CEA [HR 4.98, CI 1.06-23.46] was independently predictive of OS (p <0.01). Tumor differentiation was the most potent predictor of both PFS (poorly differentiated vs well, [HR 4.5 CI 2.01-9.94]) and OS ([poorly differentiated vs well-differentiated: [HR 13.5, CI 3.16-57.78]), p <0.05. Among patients with combined CA19-9 elevation and poorly differentiated histology, 86% recurred within a year of CRS/HIPEC (p < 0.01). Similarly, the coexistence of CEA elevation and unfavorable histology led to the lowest survival rate at two years [36%, p < 0.01]. CA-125 was not predictive of PFS or OS. CONCLUSION Elevated preoperative CA19-9 portends worse PFS, while elevated CEA predicts worse OS after CRS/HIPEC in patients with MACA. This study provides additional evidence that CA19-9 and CEA levels should be collected during standard preoperative bloodwork, while CA-125 can likely be omitted. Tumor differentiation, when added to preoperative tumor marker levels, provides powerful prognostic information. Prospective studies are required to confirm this association.
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King MC, Munoz‐Zuluaga C, Ledakis P, Studeman K, Sittig M, Gushchin V, Sardi A. Germline and somatic genetic alterations in two first-degree relatives with appendiceal low-grade mucinous carcinoma peritonei. Clin Case Rep 2020; 8:3168-3177. [PMID: 33363901 PMCID: PMC7752445 DOI: 10.1002/ccr3.3338] [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: 04/27/2020] [Revised: 07/21/2020] [Accepted: 08/12/2020] [Indexed: 11/06/2022] Open
Abstract
Comparing genetic mutations of first-degree relatives with appendiceal pseudomyxoma peritonei may explain clinical outcomes and disease pathogenesis. Molecular profiling of mucinous tumors may identify improved treatments to traditional chemotherapy.
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Affiliation(s)
| | | | | | | | - Michelle Sittig
- The Institute for Cancer CareMercy Medical CenterBaltimoreMDUSA
| | - Vadim Gushchin
- The Institute for Cancer CareMercy Medical CenterBaltimoreMDUSA
| | - Armando Sardi
- The Institute for Cancer CareMercy Medical CenterBaltimoreMDUSA
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Munoz-Zuluaga CA, King MC, Diaz-Sarmiento VS, Studeman K, Sittig M, MacDonald R, Nieroda C, Zambrano-Vera K, Gushchin V, Sardi A. Defining "Complete Cytoreduction" After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS/HIPEC) for the Histopathologic Spectrum of Appendiceal Carcinomatosis. Ann Surg Oncol 2020; 27:5026-5036. [PMID: 32705513 DOI: 10.1245/s10434-020-08844-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 06/27/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND The completeness of cytoreduction (CC) score, which quantifies residual tumor, is a major prognostic factor when treating appendiceal carcinomatosis with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). Both CC-0 and CC-1 are considered complete cytoreductions (CC-0/1) and associated with the best outcomes. We analyzed if the CC-0/1 definition is reliable across appendiceal histopathologic subtypes. METHODS A prospective database of CRS/HIPEC patients with appendiceal carcinomatosis from 1998 to 2019 was reviewed to identify patients with CC-0/1. Kaplan-Meier overall survival (OS) and progression-free survival (PFS) by CC-score for each histopathology were calculated. RESULTS Overall, 297 patients had CC-0/1. Mean age was 54 ± 12 years with 67% females. Histopathologic subtypes were 45% low-grade mucinous carcinoma peritonei (LGMCP), 27% high-grade MCP (HGMCP), 20% HGMCP with signet ring cells (HGMCP-S), and 8% goblet cell adenocarcinoma (GCAC). CC-0 and CC-1 occurred in 57% and 43% of LGMCP, 65% and 35% of HGMCP, 68% and 32% of HGMCP-S, and 79% and 21% of GCAC, respectively. OS and PFS were statistically longer for CC-0 versus CC-1 in HGMCP-S (p = 0.001 and p = 0.005, respectively) and GCAC (p < 0.001 and p < 0.001), but not in LGMCP (p = 0.098 and p = 0.398) or HGMCP (p = 0.167 and p = 0.356). CONCLUSIONS Survival outcomes for CC-0 and CC-1 after CRS/HIPEC are different for HGMCP-S and GCAC but not for LGMCP and HGMCP. In HGCMP-S and GCAC, only CC-0 should be considered a complete cytoreduction and analyzed separately from CC-1. This distinction is key to understand disease behavior, accurately address patient prognosis, and explore new treatment strategies.
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Affiliation(s)
| | - Mary C King
- The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA
| | | | - Kimberley Studeman
- The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA.,Department of Pathology, Mercy Medical Center, Baltimore, MD, USA
| | - Michelle Sittig
- The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA
| | - Ryan MacDonald
- Department of Pathology, Mercy Medical Center, Baltimore, MD, USA
| | - Carol Nieroda
- The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA
| | | | - Vadim Gushchin
- The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA
| | - Armando Sardi
- The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA.
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Munoz-Zuluaga C, Sardi A. ASO Author Reflections: When the Outliers Become Relevant. Ann Surg Oncol 2019; 26:690-691. [DOI: 10.1245/s10434-019-07663-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Indexed: 11/18/2022]
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