Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy: An Emerging Treatment Option for Advanced Goblet Cell Tumors of the Appendix

Abstract

The debate remains whether appendiceal goblet cell cancers behave as classical carcinoid or adenocarcinoma. Treatment options are unclear and reports of outcomes are scarce. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS+HIPEC) is considered optimal treatment for peritoneal involvement of other epithelial appendiceal tumors. Prospective cohorts of patients treated for advanced appendiceal tumors from three peritoneal malignancy centres were collected (1994-2011). All patients underwent complete CRS+HIPEC, when possible, or tumor debulking. Demographic and outcome data for patients with goblet cell cancers were compared to patients with low- or high-grade epithelial appendiceal tumors treated during the same time period. Details on 45 goblet cell cancer patients were compared to 708 patients with epithelial appendix lesions. In the goblet cell group, 57.8% were female, median age was 53years, median peritoneal cancer index (PCI) was 24, and CRS+HIPEC was achieved in 71.1%. These details were similar in patients with low- or high-grade epithelial tumors. Lymph nodes were involved in 52% of goblet cell patients, similar to rates in high-grade cancers, but significantly higher than in low-grade lesions (6.4%; p<0.001). At 3years, overall survival (OS) was 63.4% for goblet cell patients, intermediate between that for high-grade (40.4-52.2%) and low-grade (80.6%) tumors. On multivariate analysis, tumor histology, PCI, and achievement of CRS+HIPEC were independently associated with OS. This data supports the concept that appendiceal goblet cell cancers behave more as high-grade adenocarcinomas than as low-grade lesions. These patients have reasonable long-term survival when treated using CRS+HIPEC, and this strategy should be considered.