Repeat cytoreductive surgery with or without intraperitoneal chemotherapy for recurrent epithelial appendiceal neoplasms

Abstract

Background: With 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.Methods: A 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.Results: Some 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. Conclusion:In selected patients presenting with PSM from epithelial appendiceal neoplasms, repeat CRS performed in high-volume centres could provide survival benefits.

A case of pancreaticoduodenectomy and partial hepatic resection as repeat cytoreductive surgery for recurrent pseudomyxoma peritonei

“…Although there are no formal guidelines regarding the indications for repeat CRS with or without HIPEC criteria, patient with favorable tumor biology and the ability to achieve complete macroscopic CRS are usually selected for repeat CRS [ 5 – 7 , 10 , 18 , 19 ]. A PCI score is not a contraindication to attempt repeat CRS as long as signet cells are not present and complete cytoreduction is achieved [ 5 , 8 ].…”

“…Although there are no formal guidelines regarding the indications for repeat CRS with or without HIPEC criteria, patient with favorable tumor biology and the ability to achieve complete macroscopic CRS are usually selected for repeat CRS [ 5 – 7 , 10 , 18 , 19 ]. A PCI score is not a contraindication to attempt repeat CRS as long as signet cells are not present and complete cytoreduction is achieved [ 5 , 8 ]. Thus, the decision to repeat CRS depends on the following: absence of extraperitoneal metastases, an interval between operations of > 12 months, patient consent, and their performance status (ECOG-PS ≤ 2) [ 5 , 7 , 8 ].…”

“…A PCI score is not a contraindication to attempt repeat CRS as long as signet cells are not present and complete cytoreduction is achieved [ 5 , 8 ]. Thus, the decision to repeat CRS depends on the following: absence of extraperitoneal metastases, an interval between operations of > 12 months, patient consent, and their performance status (ECOG-PS ≤ 2) [ 5 , 7 , 8 ]. The patient’s ECOG-PS was maintained in this case, and preoperative CT and MRI showed that curative resection could be achieved.…”

“…Pseudomyxoma peritonei (PMP) is characterized by large amounts of mucinous tumors in the abdominal cavity as a result of appendiceal neoplasms [ 1 – 3 ]. Although curative treatment can be achieved by cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), the disease recurrence rate remains high, occurring in 50–80% of cases [ 4 , 5 ]. For recurrent PMP, with careful patient selection, repeat CRS with or without HIPEC can provide meaningful survival benefits with acceptable mortality and morbidity rates [ 4 – 9 ].…”

Appendiceal pseudomyxoma peritonei: predictors of recurrence and iterative surgery

“…However, despite such aggressive intervention, recurrence rates after complete cytoreduction range from 24.2% to 30%[4, 6–8]. Favourable oncological outcomes and a similar complication profile to index CRS and HIPEC have been reported in selected patients undergoing re‐do CRS[6, 9]. The selection process for iterative surgery is largely driven by clinical symptoms and disease volume[6].…”