Medline ® Abstracts for References 41,80,96,97
of 'Cancer of the appendix and pseudomyxoma peritonei'
Results of treatment of 385 patients with peritoneal surface spread of appendiceal malignancy.
Sugarbaker PH, Chang D
Ann Surg Oncol. 1999;6(8):727.
INTRODUCTION: In the past, peritoneal carcinomatosis, regardless of primary tumor type, has always been a lethal condition. Recently, special treatments using cytoreductive surgery with peritonectomy procedures combined with perioperative intraperitoneal chemotherapy have resulted in long-term survival. Appendiceal malignancy with a low incidence of liver and lymph node metastases may be especially appropriate for these aggressive local regional treatments.
METHODS: All patients treated with surgery before January 1999 are included. Patients left with gross residual disease after surgery were not given intraperitoneal chemotherapy, but were later treated with intravenous chemotherapy. The intraperitoneal chemotherapy was given in the perioperative period, starting with mitomycin C at 12.5 mg/m2 for males and 10 mg/m2 for females. For patients whose pathology showed adenomucinosis, intraperitoneal chemotherapy was limited to treatment in the operating theater with heated mitomycin C. Patients with mucinous adenocarcinoma or pseudomyxoma/adenocarcinoma hybrid had, in addition to mitomycin C, five consecutive days of intraperitoneal 5-fluorouracil at 650 mg/m2 instilled in 1-1.5 liters of 1.5% dextrose peritoneal dialysis solution. A complete cytoreduction was defined as tumor nodules<2.5 mm in diameter remaining after surgery. Thehistopathology categorized the patients as having adenomucinosis, adenomucinosis/carcinomatosis hybrid, or mucinous carcinomatosis. A previous surgical score was used to estimate the extent of previous surgical procedures.
RESULTS: The morbidity of treated patients was 27% and the mortality was 2.7%. In a multivariate analysis, prognostic factors for survival included the completeness of cytoreduction (P<.0001), the histopathological character of the appendix malignancy (P<.0001), and the extent of previous surgical interventions (P = .001). Patients with a complete cytoreduction and adenomucinosis by pathology had a 5-year survival of 86%; with hybrid pathology, survival at 5 years was 50%. Incomplete cytoreduction had a 5-year survival of 20% and 0% at 10 years.
CONCLUSIONS: Cytoreductive surgery and perioperative intraperitoneal chemotherapy can be used to salvage selected patients with peritoneal surface spread of appendiceal primary tumors. Similar strategies for other patients with peritoneal surface malignancy such as peritoneal carcinomatosis from colon or gastric cancer, peritoneal sarcomatosis, or peritoneal mesothelioma should be pursued.
Washington Cancer Institute, Washington, DC 20010, USA.
Right hemicolectomy does not confer a survival advantage in patients with mucinous carcinoma of the appendix and peritoneal seeding.
González-Moreno S, Sugarbaker PH
Br J Surg. 2004;91(3):304.
BACKGROUND: Traditionally epithelial malignancies of the appendix with or without carcinomatosis have been treated by right hemicolectomy. Recent accumulation of a large number of patients with this disease has enabled a re-evaluation of this surgical judgement.
METHODS: Clinical data on 501 patients with epithelial malignancy of the appendix were collected prospectively. All patients had peritoneal seeding at the time of referral and were treated by cytoreductive surgery and perioperative intraperitoneal chemotherapy. The main independent variable for statistical analysis was the surgical procedure used to resect the primary cancer (appendicectomy alone versus right hemicolectomy). Nineteen other clinical and pathological variables were considered as control variables. The endpoint for all analyses was survival.
RESULTS: Median follow-up after the initial diagnosis was 4 years. The rate of regional lymph node positivity was 5.0 per cent. When the incidence of lymph node metastasis was determined by histological type, it was statistically significantly higher in intestinal (66.7 per cent) than in mucinous (4.2 per cent) tumours (P<0.001). The presence of lymph node metastases had no influence on prognosis (P = 0.155). The surgical procedure (appendicectomy alone versus right hemicolectomy) had an influence on patient survival by univariate analysis (P<0.001), but not by multivariate analysis (P = 0.258).
CONCLUSION: Right hemicolectomy does not confer a survival advantage in patients with mucinous appendiceal tumours with peritoneal seeding. These data suggest that right hemicolectomy should be avoided unless metastatic involvement of the appendiceal or distal ileocolic lymph nodes is documented by biopsy, or the resection margin is inadequate.
Program in Peritoneal Surface Malignancy, The Washington Cancer Institute, Washington, DC, USA.
Total abdominal colectomy, pelvic peritonectomy, and end-ileostomy for the surgical palliation of mucinous peritoneal carcinomatosis from non-gynecologic cancer.
Stamou KM, Karakozis S, Sugarbaker PH
J Surg Oncol. 2003;83(4):197.
BACKGROUND AND OBJECTIVES: The optimal management of symptomatic advanced peritoneal carcinomatosis of non-gynecologic origin is not defined. Historic controls of surgical efforts report high postoperative mortality and morbidity rates with equivocal palliation. Novel surgical procedures need to be tested in terms of the impact on survival and quality of life.
STUDY DESIGN: We studied 46 consecutive patients who underwent total abdominal colectomy, pelvic peritonectomy with construction of an end-ileostomy for palliation of peritoneal carcinomatosis.
RESULTS: Total abdominal colectomy, pelvic peritonectomy, and end-ileostomy was successfully performed in 46 patients of median age of 54.4 years. Overall median survival was 10.7 months, with a mean follow-up period of 12 months. Patients with appendiceal malignancy had a median survival of 19.7 months. Prognosis was poorer for patients with colon cancer, who had a median survival of 7.0 months, while patients with primary peritoneal carcinomatosis had a median of 7.8 months. Postoperative morbidity and mortality rates were 19.5 and 8.6%,respectively.
CONCLUSIONS: Total abdominal colectomy, pelvic peritonectomy, and end-ileostomy is a technically feasible procedure and is advocated for the palliation of patients with peritoneal carcinomatosis of appendiceal origin. It is not clear if the procedure should be advocated for more invasive gastrointestinal malignancies.
Washington Cancer Institute, Washington Hospital Center, NW, Washington, DC 20010, USA.
Prospective morbidity and mortality assessment of cytoreductive surgery plus perioperative intraperitoneal chemotherapy to treat peritoneal dissemination of appendiceal mucinous malignancy.
Sugarbaker PH, Alderman R, Edwards G, Marquardt CE, Gushchin V, Esquivel J, Chang D
Ann Surg Oncol. 2006;13(5):635. Epub 2006 Mar 10.
BACKGROUND: Appendiceal mucinous neoplasms present, in most patients, with peritoneal dissemination at the time of initial diagnosis. Patients may have a borderline tumor showing disseminated peritoneal adenomucinosis or an aggressive malignancy identified as peritoneal mucinous adenocarcinoma. Patients with these diagnoses were treated by cytoreductive surgery and perioperative intraperitoneal chemotherapy.
METHODS: A database was established in 1998 that prospectively evaluated the morbidity and mortality of this group of patients. By using common toxicity grading criteria, 8 categories were scored on a grade of I to V. Grade IV indicated that the adverse event required urgent and definitive intervention: often a return to the operating room or to the surgical intensive care unit. Grade V indicated that the adverse events resulted in the patient's death. Adverse events were tabulated for each cytoreduction performed in these appendiceal malignancy patients.
RESULTS: There were 356 procedures in patients taken to the operating room who received cytoreductive surgery with peritonectomy procedures plus heated intraoperative intraperitoneal chemotherapy. Only patients who had this combined treatment at our institution were included in the analysis. The total 30-day or in-hospital mortality was 2.0%. Nineteen percent of procedures were accompanied by at least one grade IV adverse event, and 11.1% of patients returned to the operating room. The most common category of grade IV complications was hematological (28%), followed by gastrointestinal (26%).
CONCLUSIONS: The mortality of 2.0% and the overall grade IV morbidity of 19% in these patients may be acceptable in light of modern standards for the management of gastrointestinal cancer.
Washington Cancer Institute, 106 Irving Street, N.W., Suite 3900, Washington, DC 20010, USA. firstname.lastname@example.org