Prognostic factors for survival in advanced appendiceal cancers

Predicting Survival in Mucinous Adenocarcinoma of the Appendix: Demographics, Disease Presentation, and Treatment Methodology

BACKGROUND

Mucinous adenocarcinoma of the appendix (MACA) follows a complex disease course with variable survival. Large-scale predictive modeling may determine subtle yet important prognostic factors otherwise unseen in smaller cohort analyses.

METHODS

Patients with MACA were identified from the Surveillance, Epidemiology, and End Results (SEER) Research Plus database (2005-2019). Primary, secondary, and tertiary outcomes were disease-specific survival (DSS), overall survival (OS), and average annual percent change (AAPC) in incidence.

RESULTS

Among 4,258 included patients, MACA was most frequently diagnosed at 50 to 69 years (52.0%), with female preponderance (55.9%). MACA incidence AAPC was 3.8 (95% confidence interval [CI] 1.9-5.9). For patients with exclusive, first-diagnosis MACA included in survival analysis (3,222 patients), median DSS and OS were 118 and 88 months, respectively. In DSS-based multivariable analysis, worse prognosis was associated with non-Hispanic Black background (HR 1.36, 95% CI 1.02-1.82; p = 0.036), high grade (grade 3 HR 3.10, 95% CI 2.44-3.92; p < 0.001), lymphatic spread (HR 2.73, 95% CI 2.26-3.30; p < 0.001), and distant metastasis (HR 5.84, 95% CI 3.86-8.83; p < 0.001). In subcohort analysis of patients with rationale for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC, 2,387 patients), CRS-HIPEC was associated with survival benefit compared with surgery alone but only for moderate-grade tumors (median DSS/OS 138/138 vs. 116/87 months; p < 0.001).

CONCLUSIONS

Mucinous adenocarcinoma of the appendix incidence is increasing in the United States. Survival rates are affected by both demographics and classical risk factors, and CRS-HIPEC-associated survival benefit predominantly occurs in moderate-grade tumors. Further exploration of biologic and clinicopathologic features may enhance risk stratification for this disease.

Surgical outcomes and predictors of overall survival of stage I-III appendiceal adenocarcinoma: Retrospective cohort analysis of the national cancer database

BACKGROUND

This study aimed to determine predictors of overall survival (OS) after surgical treatment of stage I-III appendiceal adenocarcinoma and compare the outcomes of partial colectomy and hemicolectomy.

METHODS

A retrospective analysis of the U.S. National Cancer Database (NCDB) including patients who underwent surgery for stage I-III appendiceal adenocarcinoma between 2005 and 2019 was conducted. A propensity-score matched analysis was undertaken to compare the outcomes of partial and hemicolectomy and multivariate analysis was performed to determine predictive factors of OS. The main outcome was OS and its independent predictors.

RESULTS

2607 patients (51.6 % male) with a mean age of 61.6 ± 13.9 years were included. 61.7 % of patients underwent hemicolectomy while 31.7 % underwent partial colectomy. After matching, partial colectomy, and hemicolectomy had similar OS (117.3 vs 117.2 months; p = 0.08), positive resection margins, short-term mortality, and 30-day readmission. The hemicolectomy group was associated with more examined lymph nodes and longer hospital stays. Older age (HR: 1.047, p < 0.0001), rural residence area (HR: 3.6, p = 0.025), higher Charlson score (HR: 1.6, p = 0.016), signet-ring cell carcinoma (HR: 2.37, p = 0.009), adjuvant systemic treatment (HR: 1.55, p = 0.015), positive surgical margins (HR: 1.83, p = 0.017), positive lymph nodes number (HR: 1.09, p < 0.0001), and examined lymph nodes number (HR: 0.962, p = 0.001) were independent predictors of OS.

CONCLUSIONS

Partial colectomy and hemicolectomy had similar OS and clinical outcomes. Older age, rural residence, higher Charlson score, signet-ring pathology, adjuvant systemic treatment, positive surgical margins, positive lymph node number, and examined lymph node number were independent predictors of OS.

An Ex Vivo Organotypic Culture Platform for Functional Interrogation of Human Appendiceal Cancer Reveals a Prominent and Heterogenous Immunological Landscape

PURPOSE

Epithelial neoplasms of the appendix are difficult to study preclinically given their low incidence, frequent mucinous histology, and absence of a comparable organ in mice for disease modeling. Although surgery is an effective treatment for localized disease, metastatic disease has a poor prognosis as existing therapeutics borrowed from colorectal cancer have limited efficacy. Recent studies reveal that appendiceal cancer has a genomic landscape distinct from colorectal cancer and thus preclinical models to study this disease are a significant unmet need.

EXPERIMENTAL DESIGN

We adopted an ex vivo slice model that permits the study of cellular interactions within the tumor microenvironment. Mucinous carcinomatosis peritonei specimens obtained at surgical resection were cutoff using a vibratome to make 150-μm slices cultured in media.

RESULTS

Slice cultures were viable and maintained their cellular composition regarding the proportion of epithelial, immune cells, and fibroblasts over 7 days. Within donor specimens, we identified a prominent and diverse immune landscape and calcium imaging confirmed that immune cells were functional for 7 days. Given the diverse immune landscape, we treated slices with TAK981, an inhibitor of SUMOylation with known immunomodulatory functions, in early-phase clinical trials. In 5 of 6 donor samples, TAK981-treated slices cultures had reduced viability, and regulatory T cells (Treg). These data were consistent with TAK981 activity in purified Tregs using an in vitro murine model.

CONCLUSIONS

This study demonstrates an approach to study appendiceal cancer therapeutics and pathobiology in a preclinical setting. These methods may be broadly applicable to the study of other malignancies.

Prognostic value of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio on low-grade appendiceal mucinous neoplasm: A single tertiary hospital experience

BACKGROUND

Low-grade appendiceal mucinous neoplasm (LAMN) is a rare disease, which prognostic factors were difficult to evaluate. Inflammation markers, like neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR), were used as prognosticators for various cancers. This study aimed to investigate the prognostic value of pretreatment NLR and PLR on LAMN.

METHODS

From January 2000 to September 2018, there were 57 patients diagnosed with LAMN in Taipei Veterans General Hospital. Patients diagnosed with mucinous cystadenoma, mucinous tumor with uncertain malignant potential before 2010 were also included based on previous classification. Clinical and pathological data were collected. Patients were separated into high-NLR (NLR-H) and low-NLR (NLR-L) groups according to cutoff value of 3. Similarly, they were separated into high-PLR (PLR-H), and low-PLR (PLR-L) groups with cutoff value of 300. Overall survival (OS) and recurrence-free survival (RFS) were analyzed.

RESULTS

Among all patients, the median follow-up time was 42 months. Age, gender, clinical manifestations, type of surgery, and T stage were similar in different NLR and PLR groups. Both NLR-H and PLR-H groups had higher rate of M1 stage of diseases (22.7% vs 9.4%, p = 0.04; 57.1% vs 8.8%, p < 0.01, respectively). PLR-H group had more presence of pseudomyxoma peritonei (PMP) (57.1% vs 15.2%, p = 0.03). In univariate analysis, factors such as age, gender, tumor perforation, and operation did not have impact on OS nor RFS. On the other hand, M1b stage is the only significantly poor prognostic factor on RFS (hazard ratio, 57.96, 95% CI, 5.16-651.23, p < 0.01).

CONCLUSION

Both NLR-H and PLR-H had more M1 stage of diseases, but they were not correlated to OS nor RFS. PLR-H group had higher rate of presence PMP. Nevertheless, patients with LAMN and cellular PMP (M1b stage) had a higher rate of recurrence, and other factors showed no statistical difference in OS nor RFS.

Prevalence of Carcinoma in Appendectomy Specimens for Patients Presenting With Acute Appendicitis: A Single-Center Study

Introduction Acute appendicitis is the most common general surgical emergency globally. Its etiology includes the presence of luminal obstruction by faecoliths, lymphoid hyperplasia, impacted stool, and rarely by appendiceal or caecal cancer. Malignancy related to acute appendicitis is usually seen in the older age group. Aim To identify the subset rate of patients operated for acute appendicitis who have appendiceal carcinoma and analyze the outcome of their post-operative management. Material and methods A retrospective study of a cohort of 529 patients aged > 40 diagnosed with acute appendicitis with subsequent appendectomy in the period between 1 January 2014 and 31 December 2019 at Basildon and Thurrock University Hospital, Essex, United Kingdom was conducted. We analyzed the clinical data of the cohort including demographic information, diagnosis, pre-operative imaging, histological diagnosis as well as post-operative management where indicated. Results The median age of patients was 54.5 years (range 40-92). The male to female ratio in the appendicectomy cohort was 1:1.1. About 45% were aged 40-49 years, 24.8% were aged 50-59 and 30.2% were ≥60 years. Post-operative histology revealed acute appendicitis in 82.4% of the group. In 11% of the patients, the histology revealed the presence of other benign pathology as mucocele of the appendix, acute diverticulitis, follicular hyperplasia, and fibrous obliteration. The diagnosis of appendicular malignancy was seen in 1.9%. Conclusion Incidental appendiceal cancers in the resected specimens after acute appendicitis are rare but may be associated with a poor prognosis. It is recommended to consider such diagnosis in particular when dealing with acute appendicitis in older patients with longer symptom history, and in presence of peri-appendicular mass.

Lymphocyte-to-monocyte ratio predicts survival after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

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.

Prognostic Value of the Pretreatment Systemic Immune-Inflammation Index in Patients with Colorectal Cancer

Background

Multiple studies have reported the significance of the systemic immune-inflammation index (SII) in the prognosis of colorectal cancer (CRC), but no consensus has yet been reached. The purpose of this study was to systematically assess the prognostic value of SII in patients with CRC.

Materials and Methods

We performed a systematic literature search in PubMed, Embase, and the Cochrane Library for eligible studies. The correlation between pretreatment SII and overall survival (OS), disease-free survival (DFS), and progression-free survival (PFS) in CRC patients was evaluated by combining the hazard ratio (HR) and 95% confidence interval (CI).

Results

Twelve studies involving 3919 patients were included. Comprehensive analysis results showed that high SII indicated poor OS in CRC patients (HR = 1.777, 95% CI: 1.328-2.376). Compared with patients with low SII values, patients with high SII had lower PFS (HR = 1.658, 95% CI: 1.189-2.311). Subgroup analysis further verified the above results.

Conclusions

SII may be a noninvasive and powerful tool for predicting survival outcomes in CRC patients. However, more well-designed studies are needed to validate our findings.

Epidemiology of and prognostic factors for appendiceal carcinomas: a retrospective, population-based study

BACKGROUND

The aim of this study is to evaluate the epidemiology of and prognostic factors for appendiceal carcinomas (ACs).

METHODS

All cases of ACs registered in the Surveillance, Epidemiology, and End Results (SEER) database from 1973 to 2014 were retrospectively identified in this study. Age-adjusted incidence and survival rates were calculated.

RESULTS

We analyzed 7170 patients with ACs. We observed a significant increase in the reported annual age-adjusted incidence of ACs from 1973 (0.18/100,000) to 2014 (1.11/100,000). The elevation of the incidence was noted in all the histological types, stages, and grades. The most common histological type varied by race, with the appendiceal mucinous adenocarcinoma (AMA) being the most common in white, Asian/Pacific Islander, and American Indian/Alaskan Native patients, and the appendiceal adenocarcinoma (AA) being the most common in African American patients. In multivariate analysis of patients with all ACs, gender (P < 0.001), year of diagnosis (P < 0.001), age (P < 0.001), race (P < 0.001), tumor grade (P < 0.001), disease stage (P < 0.001), retrieved regional lymph nodes (P < 0.001), type of surgery performed (P = 0.002), and histologic subtype (P < 0.001) were predictors of outcome. Survival time for all ACs increased from the 1973-1993 period to the 1994-2014 period (HR 0.76; 95% CI, 0.69 to 0.85). Additionally, the 5-year survival rates were 88% for malignant carcinoid, 70% for goblet cell carcinoid, 51% for colonic type adenocarcinoma, 59% for mucinous adenocarcinoma, and 25% for signet ring cell type.

CONCLUSIONS

We observed increased reported incidence of ACs and increased survival durations over time, suggesting that clinicians pay more attention to ACs and mastering the characteristic of these tumors.

Prognostic value of pretreatment systemic immune-inflammation index in patients with gastrointestinal cancers

BACKGROUND

Numerous studies have reported the relationship between systemic immune-inflammation index (SII) and prognosis in gastrointestinal (GI) cancers, but no consensus has been reached. We aimed to systematically evaluate the prognostic value of SII in patients with GI cancers.

METHODS

Relevant published papers regarding the prognostic value of SII in patients with GI cancers were obtained from a number of electronic databases. The overall hazard ratios and the corresponding 95% confidence intervals (95% CIs) were calculated using a fixed or random effects model to assess the relationship between SII and prognosis through Stata SE 12.0.

RESULTS

A total of 24 eligible published articles with 9,626 patients were included. From the pooled results, we found that high SII indicated worse overall survival (OS) in patients with GI cancers (HR = 1.52, 95%CI: 1.29-1.74). And patients with high SII had poorer disease-free survival (HR: 2.28, 95% CI: 1.46-3.10), time to recurrence (HR: 1.70, 95% CI: 1.11-2.30), and recurrence-free survival (HR: 1.60, 95% CI: 1.19-2.00) when compared with those with low SII values.

CONCLUSIONS

SII might serve as a noninvasive and powerful tool for predicting survival outcome in patients with GI cancers.