Prognostic Value of Circulating Tumor Markers in Patients with Pseudomyxoma Peritonei Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

Encouraging results have been recently reported in selected patients affected by pseudomyxoma peritonei (PMP) treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). The selection factors predicting clinical outcome are still a matter of clinical investigation. We assessed the prognostic reliability of serum tumor markers in a large series of patients with PMP undergoing CRS and HIPEC.

METHODS

Sixty-two patients with PMP were operated on at a single institution with the intent of performing adequate CRS (residual tumor nodules </=2.5mm) and HIPEC. Baseline and serial marker measurements were prospectively collected and tested by multivariate analysis with respect to adequate cytoreduction, overall (OS) and progression-free (PFS) survival, along with the following variables: age, sex, performance status, prior surgical score, histological subtype, prior systemic chemotherapy, disease extent, completeness of cytoreduction.

RESULTS

Baseline diagnostic sensitivity was 72.6% for CEA, 58.1% for CA19.9, 58.7% for CA125, 36.1% for CA15.3. Fifty-three patients underwent adequate CRS and HIPEC; gross residual tumor was left after surgery in nine. Adequate CRS was performed in 19/27 patients with elevated and in 19/19 with normal baseline CA125 (P = .0140). The other markers were unable to predict the completeness of CRS by univariate analysis. Baseline elevated CA19.9 was an independent predictor of reduced PFS; inadequate CRS and aggressive histology were independent prognostic factors for both reduced OS and PFS.

CONCLUSION

Normal CA125 correlated to the likelihood to achieve adequate CRS, which is a significant prognostic factor for PMP. Increased baseline CA19.9 was an independent predictor of worse PFS after CRS and HIPEC.

Elevated tumour markers prior to complete tumour removal in patients with pseudomyxoma peritonei predict early recurrence

OBJECTIVE

To assess the potential value of pre-operative CEA, CA 125 and CA 19-9 in identifying Pseudomyxoma peritonei (PMP) patients at risk of recurrence following complete cytoreductive surgery and intraperitoneal chemotherapy.

METHOD

Between March 1996 and October 2001, 35 patients, with documented pre-operative tumour marker measurements, underwent complete cytoreduction. Outcome in the 32 survivors was recorded.

RESULTS

Median age was 53 years (range: 32-74). There were 17[53%] females. In 9/32[28%] all tumour markers were normal. The most common abnormality was elevated CEA level in 14/32[44%]. Median follow up was 23 months (range: 11-74). Recurrence was detected in 8/32[25%]. The 2-year recurrence free interval was 53% in those with elevated CEA compared with 94% with normal CEA. The 2-year disease free intervals were 100% in 9 patients with normal preop markers compared with 66% for the group with at least one abnormal marker.

CONCLUSION

PMP patients with elevated CEA, or more than one abnormal serum tumour maker, are at risk of developing recurrent disease.

Pseudomyxoma peritonei with high serum CA19-9: report of three cases

Pseudomyxoma peritonei (PMP) is an unusual form of intraabdominal neoplasm that produces a large amount of extracellular mucin. It is often associated with mucinous tumors of gastrointestinal tract or ovary. Herein, we report 3 patients with pseudomyxoma peritonei with high serum carbohydrate antigen 19-9 (CA19-9) levels. The first patient, who had a CA19-9 level of 1132 U/ml, had well-differentiated rectal cancer and died of chemotherapy complications, pneumonia and septic shock; one month after admission. The other 2 cases with CA19-9 levels of 2520 U/ml and 679 U/ml had tumors of unknown origins and had survived more than 1 year and 3 months after treatment, respectively. Usually, elevated serum CA19-9 levels are found in patients with pancreatic, biliary, colorectal, gastric or liver cancers. However, many studies have shown high serum CA19-9 levels are associated with mucinous carcinoma. Immunochemical studies also showed positive staining of CA19-9 in mucinous tumors. PMP is composed of large amounts of mucin, therefore, we suggest that serum and ascites CA19-9 levels should be routinely checked in patients with PMP.

A clinical study on pseudomyxoma peritonei

To elucidate the clinical entity of pseudomyxoma peritonei, nine patients (male: female = 6:3) who had been treated in Chang Gung Memorial Hospital in the past 13 years were reviewed. The male patients with original appendiceal tumour were older than the male patients with original colon cancer or indefinite tumour (70, 67 and 67 years vs 42, 27 and 50 years). In addition, the former group survived in a disease-free status for 28 months on average, while the latter group died within 2 years. Echogenic ascites and diffuse low-attenuation intra-abdominal masses with scalloping on the surface of liver detected by ultrasonography and by computerized tomography, respectively, were found in most of the patients. Elevation of the serum carcinoembryonic antigen (CEA) during recurrence of the disease was also noted. This series suggested that: (i) the pre-operative diagnosis could be made with careful physical examination in conjunction with sonography or computerized tomography; (ii) the prognosis was better in patients with tumour of appendiceal origin; and (iii) serum CEA might be valuable for early detection of recurrence.