Abstract
BackgroundWith recurrence rates after primary cytoreductive surgery (CRS) in excess of 50 per cent, repeat CRS is being performed increasingly, but survival outcomes have not been reported widely. This study examined the outcomes following repeat CRS for appendiceal cancer with peritoneal surface malignancy (PSM), and evaluated its feasibility and safety.MethodsA retrospective cohort of patients who had surgery between 1996 and 2018 were analysed. Patients who underwent a single CRS procedure with or without heated intraperitoneal chemotherapy (HIPEC) were compared with those who had multiple procedures with or without HIPEC. Perioperative morbidity and survival outcomes were analysed.ResultsSome 462 patients were reviewed, 102 of whom had repeat procedures. For high‐grade tumours, patients who had a single CRS procedure had significantly reduced overall survival (OS) compared with those who had repeat CRS (55·6 versus 90·7 months respectively; P = 0·016). For low‐grade tumours, there was no difference in OS (P = 0·153). When patients who had a single procedure were compared with those who had multiple procedures, there was no significant difference in major morbidity (P = 0·441) or in‐hospital mortality (P = 0·080). For multiple procedures, no differences were found in major morbidity (P = 0·262) or in‐hospital mortality (P = 0·502) when the first procedure was compared with the second. For low‐grade cancers, the peritoneal carcinomatosis index was a significant prognostic factor for OS (hazard ratio (HR) 1·11, 95 per cent c.i. 1·05 to 1·17; P < 0·001), whereas for high‐grade cancers repeat CRS (HR 0·57, 0·33 to 0·95; P = 0·033), complete cytoreduction score (HR 1·55, 1·01 to 2·40; P = 0·046) and presence of signet ring cells (HR 2·77, 1·78 to 4·30; P < 0·001) were all significant indicators of long‐term survival.ConclusionIn selected patients presenting with PSM from epithelial appendiceal neoplasms, repeat CRS performed in high‐volume centres could provide survival benefits.
Highlights
Primary epithelial appendiceal neoplasms are rare primary malignancies of the gastrointestinal tract, accounting for less than 0⋅5 per cent of all gastrointestinal neoplasms[1,2,3], and representing only 1 per cent of colorectal cancers[4]
Data from the last two decades show that cytoreductive surgery (CRS)–heated intraperitoneal chemotherapy (HIPEC) is associated with a marked improvement in long-term survival, with reported 10-year survival rates above 60 per cent5,9,10,16,21 – 23
Disease recurrence after complete cytoreduction has been reported in up to 50 per cent of patients treated with CRS–HIPEC9
Summary
Primary epithelial appendiceal neoplasms are rare primary malignancies of the gastrointestinal tract, accounting for less than 0⋅5 per cent of all gastrointestinal neoplasms[1,2,3], and representing only 1 per cent of colorectal cancers[4]. When patients who had a single procedure were compared with those who had multiple procedures, there was no significant difference in major morbidity (P = 0⋅441) or in-hospital mortality (P = 0⋅080). For low-grade cancers, the peritoneal carcinomatosis index was a significant prognostic factor for OS (hazard ratio (HR) 1⋅11, 95 per cent c.i. 1⋅05 to 1⋅17; P < 0⋅001), whereas for high-grade cancers repeat CRS (HR 0⋅57, 0⋅33 to 0⋅95; P = 0⋅033), complete cytoreduction score (HR 1⋅55, 1⋅01 to 2⋅40; P = 0⋅046) and presence of signet ring cells (HR 2⋅77, 1⋅78 to 4⋅30; P < 0⋅001) were all significant indicators of long-term survival. Conclusion: In selected patients presenting with PSM from epithelial appendiceal neoplasms, repeat CRS performed in high-volume centres could provide survival benefits
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