Cellularity in low-grade Pseudomyxoma peritonei impacts recurrence-free survival following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy
Documentation of cellularity in Pseudomyxoma peritonei (PMP) is not performed on a regular basis in everyday clinical practice, but is recommended by the PSOGI (Peritoneal Surface Oncology Group International). We investigated the impact of cellularity in PMP following cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) on recurrence-free survival.
Data from 25 patients with low-grade (American Joint Committee on Cancer grade G1) PMP were retrospectively evaluated. Cellularity was categorized as acellular mucin, scant (< 2% cellularity), moderate (2–19% cellularity), or high cellularity (> 20% cellularity). Impact of cellularity, PCI, CC-score, and HIPEC regimen on recurrence-free and overall survival was primarily assessed.
Assessment of cellularity showed acellular mucin in ten patients (40%), scant cellularity in 11 (44%) patients, moderate cellularity in one (4%) patient, and high cellularity in three (12%) patients. Median PCI was 15 (range, 1–39). A CC-0 score was achieved in 13 (52%) patients and a CC-1 score was achieved in 12 (48%) patients. After a median follow-up of 25 (range, 2–74) months, all patients were still alive. Overall, four (16%) patients suffered from recurrent disease after a median of 38 (range, 36–60) months. PCI above 17 (p = 0.03) and moderate and high cellularity (p = 0.007) were statistically significantly associated with recurrent disease. CC-score and HIPEC compound used did not impact on recurrence-free survival.
Recurrent disease occurs more often in patients with PCI values above 17 and with moderate and high cellularity in low-grade PMP. Pathological assessment of cellularity is crucial for identification of patients at risk for recurrence.
KeywordsPseudomyxoma peritonei Low-grade Cellularity HIPEC Recurrence
Can Yurttas: analysis and interpretation of data, critical review of the manuscript; Alfred Königsrainer: critical review of the manuscript, analysis and interpretation of data; Philipp Horvath: acquisition of data, drafting of the manuscript, analysis and interpretation of data; Philipp Birk: critical review of the manuscript; Florian Struller: critical review of the manuscript.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
- 1.Carr NJ, Cecil TD, Mohamed F, Sobin LH, Sugarbaker PH, González-Moreno S, Taflampas P, Chapman S, Moran BJ (2016) A consensus for classification and pathologic reporting of Pseudomyxoma Peritonei and associated appendiceal neoplasia: the results of the Peritoneal Surface Oncology Group International (PSOGI) Modified Delphi Process. Am J Surg Pathol 40(1):14–26. https://doi.org/10.1097/PAS.0000000000000535 CrossRefGoogle Scholar
- 2.Choudry HA, Pai RK, Shuai Y, Ramalingam L, Jones HL, Pingpank JF, Ahrendt SS, Holtzman MP, Zureikat AH, Zeh HJ, Bartlett DL (2018) Impact of cellularity on oncologic outcomes following cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion for Pseudomyxoma Peritonei. Ann Surg Oncol 25(1):76–82. https://doi.org/10.1245/s10434-017-6214-7 CrossRefGoogle Scholar
- 4.Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213. https://doi.org/10.1097/01.sla.0000133083.54934.ae CrossRefGoogle Scholar
- 11.Pai RK, Longacre TA (2005) Appendiceal mucinous tumors and pseudomyxoma peritonei: histologic features, diagnostic problems, and proposed classification. Adv Anat Pathol 12(6):291–311. https://doi.org/10.1097/01.pap.0000194625.05137.51 CrossRefGoogle Scholar
- 13.Carr NJ, Sobin LH (1996) Unusual tumors of the appendix and pseudomyxoma peritonei. Semin Diagn Pathol 13(4):314–325Google Scholar
- 15.Bradley RF, Stewart JH 4th, Russell GB, Levine EA, Geisinger KR (2006) Pseudomyxoma peritonei of appendiceal origin: a clinicopathologic analysis of 101 patients uniformly treated at a single institution, with literature review. Am J Surg Pathol 30(5):551–559. https://doi.org/10.1097/01.pas.0000202039.74837.7d CrossRefGoogle Scholar
- 16.Chua TC, Moran BJ, Sugarbaker PH, Levine EA, Glehen O, Gilly FN, Baratti D, Deraco M, Elias D, Sardi A, Liauw W, Yan TD, Barrios P, Gómez Portilla A, de Hingh IH, Ceelen WP, Pelz JO, Piso P, González-Moreno S, Van Der Speeten K, Morris DL (2012) Early- and long-term outcome data of patients with pseudomyxoma peritonei from appendiceal origin treated by a strategy of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. J Clin Oncol 30(20):2449–2456. https://doi.org/10.1200/JCO.2011.39.7166 CrossRefGoogle Scholar
- 18.Honoré C, Caruso F, Dartigues P, Benhaim L, Chirica M, Goéré D, Elias D (2015) Strategies for preventing Pseudomyxoma Peritonei after resection of a mucinous neoplasm of the appendix. Anticancer Res 35(9):4943–4947Google Scholar
- 20.Bozkurt M, Doganay S, Kantarci M, Yalcin A, Eren S, Atamanalp SS, Yuce I, Yildirgan MI (2011) Comparison of peritoneal tumor imaging using conventional MR imaging and diffusion-weighted MR imaging with different b values. Eur J Radiol 80(2):224–228. https://doi.org/10.1016/j.ejrad.2010.06.004 CrossRefGoogle Scholar