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Appendiceal Neoplasms With Peritoneal Dissemination: Outcomes After Cytoreductive Surgery and Intraperitoneal Hyperthermic Chemotherapy

¹ Department of General Surgery, Surgical Oncology Service, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157
² Department of Public Health Sciences, Section on Biostatistics, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157
³ Pathology Department, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157
⁴ Department of General Surgery, Surgical Oncology Section, Creighton University School of Medicine, Omaha, Nebraska

Correspondence: Address correspondence and reprint requests to: Edward A. Levine, MD; E-mail: elevine{at}wfubmc.edu.

Background: Appendiceal neoplasms frequently present with peritoneal dissemination (PD) and have a clinical course marked by bowel obstruction and subsequent death. Few data have correlated outcome with appendiceal histology after cytoreductive surgery and intraperitoneal hyperthermic chemotherapy (IPHC). We have reviewed our experience with cytoreductive surgery and IPHC for PD from the appendix.

Methods: A total of 110 cases of PD from proven appendiceal neoplasms treated with IPHC were identified from a prospectively managed database. Tumor samples were classified on pathologic review as disseminated peritoneal adenomucinosis (n = 55), peritoneal mucinous carcinomatosis (PMCA) with intermediate features (n = 18), PMCA (n = 29), or high-grade nonmucinous lesions (n = 8). A retrospective review was performed with long-term survival as the primary outcome measure.

Results: A total of 116 IPHCs were performed on 110 patients for appendiceal PD between 1993 and 2004. The 1-, 3-, and 5-year survival rates for all cases were 79.9% ± 4.1%, 59.0% ± 5.7%, and 53.4% ± 6.5%, respectively. When stratified by histology, disseminated peritoneal adenomucinosis and intermediate tumors had better 3-year survival rates (77% ± 7% and 81% ± 10%) than PMCA and high-grade nonmucinous lesions (35% ± 10% and 15% ± 14%; P = .0032 for test of differences between groups). Age at presentation (P = .0134), performance status (P < .0001), time between diagnosis and IPHC (P = .0011), resection status (P = .0044), and length of hyperthermic chemoperfusion (P = .0193) were independently associated with survival.

Conclusions: The data show that long-term survival is anticipated in most patients who are treated with cytoreduction and IPHC for appendiceal PD. The findings presented herein underscore the important prognostic characteristics that predict outcome after IPHC in patients with PD. In all, this work establishes a framework for the consideration of IPHC in future trials for appendiceal PD.

Key Words: Peritoneal dissemination • Disseminated peritoneal adenomucinosis • Peritoneal mucinous carcinomatosis • Intraperitoneal hyperthermic chemotherapy • Mitomycin C • Cytoreductive surgery

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