M. Mavros1, L. Bijelic1, U. Hyder1, A. Firoozmand1, C. Ihemelandu1, P. Sugarbaker1 1MedStar Washington Hospital Center,Department Of Surgery,Washington, DC, USA
Introduction: Appendiceal cancer most commonly metastasizes to the peritoneum. Cytoreductive surgery (CRS) with heated intraperitoneal chemotherapy (HIPEC) has become the leading treatment modality for peritoneal metastases. We sought to analyze clinical outcomes after CRS and HIPEC for appendiceal cancer in a recent cohort of patients treated at a large referral center and identify prognostic factors and predictors of recurrence.
Methods: Patients undergoing CRS with HIPEC for appendix cancer in a large tertiary care referral center between January 2007 and December 2009 were identified. Prospectively collected data were analyzed, including standard preoperative, intraoperative, and postoperative variables; the impact of prior surgical score (PSS), peritoneal cancer index (PCI), and completeness of cytoreduction score (CCS) was specifically assessed. Multivariate Cox regression models were developed to identify factors independently predicting overall survival and recurrence.
Results: A total of 134 patients were analyzed. Median age was 51 years and 53% were female. Roughly half had previous abdominal operations (PSS≥2, 53%), extensive peritoneal dissemination (PCI≥21, 52%), or the PMCA variant (54%); few had lymph node metastases (11%). Median operative time was 9 hours, and most of the patients received RBC (73%) or FFP (47%) transfusions; 30-day mortality was 0.7%. Half of the patients underwent early postoperative intraperitoneal chemotherapy (49%), and a large proportion experienced at least one postoperative complication (minor, 37%; major, 25%). Overall survival (OS) at 5 years was 74.4%; 5-year recurrence-free survival (RFS) of patients with a complete cytoreduction (CCS≤1) was 65.5%. Factors independently predicting shorter survival included the PMCA variant [Hazards Ratio (HR)=12.74, 95% CI: 3.77–43.05)], lymph node metastasis [HR=2.58 (1.15–5.79)], and incomplete cytoreduction [CCS≥2, HR=5.93 (2.85–12.34)]. Similarly, factors predicting recurrence included the PMCA variant [HR=7.03 (3.35–14.78)] and lymph node metastasis [HR=4.00 (1.74–9.19)]. An incomplete cytoreduction was associated with the PMCA variant (p<0.001), but also more advanced peritoneal disease (PCI≥11, p=0.012) and prior abdominal surgeries (PSS≥2, p=0.033).
Conclusion: CRS with HIPEC can be performed with acceptable morbidity and mortality at an experienced referral center and achieve long term survival for patients with advanced appendix cancer. Histologic subtype and lymph node metastasis, along with complete cytoreduction are the most important predictors of overall survival. Efforts should be made for timely definitive CRS/HIPEC, avoiding prior non-definitive abdominal operations when possible.
