Despite meticulous preoperative diagnostics, aborted hyperthermic intraperitoneal chemotherapy (AHIPEC) is a common, unsuccessful outcome of curative cytoreductive surgery (CRS)/HIPEC.
The aim of this study was to evaluate the association between AHIPEC and preoperative risk factors of patients with mucinous appendiceal cancer (AC).
A single-institute, case–control study was conducted using a prospective database. Potentially resectable patients with peritoneal carcinomatosis of mucinous AC origin with AHIPEC between October 1994 and February 2019 were identified. Preoperative risk factors were reviewed. Analysis was conducted by tumor grade: low-grade, high-grade, and signet ring cell carcinoma (high-S). All available tumor-type-matched successful CRS/HIPEC controls were obtained from the same database. Univariable and multivariable analyses were performed.
Overall, 21, 44, and 15 AHIPEC cases and 153, 133, and 53 tumor-matched controls were identified for low-grade, high-grade, and high-S populations, respectively. Multivariable analysis revealed preoperative cancer antigen (CA) 19-9 > 1 upper limit of normal (ULN) [odds ratio (OR) 6.32; p = 0.014], CA125 > 2 ULN (OR 7.02; p = 0.039), C-reactive protein (CRP) > 2.5 mg/L (OR 13.7; p = 0.001), and previous HIPEC (OR 7.5; p = 0.031) were significantly associated with AHIPEC in the low-grade population. Preoperative CRP > 2.5 mg/L (OR 7.77; p < 0.0001) and previous HIPEC (OR 4.69; p = 0.004) were associated with AHIPEC in a multivariable model for high-grade AC. No single factor showed a significant association with AHIPEC in high-S patients.
Risk factors vary for AHIPEC among low-grade, high-grade, and high-S AC histology. Elevated preoperative CA19-9, CA125, CRP, and previous HIPEC should be considered in the selection process for CRS/HIPEC in low-grade AC, as well as elevated CRP and previous HIPEC in high-grade AC, to avoid unnecessary surgery.
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Sugarbaker PH. New standard of care for appendiceal epithelial neoplasms and pseudomyxoma peritonei syndrome? The Lancet Oncology. 2006;7(1):69–76.
van Oudheusden TR, Braam HJ, Luyer MD, et al. Peritoneal cancer patients not suitable for cytoreductive surgery and HIPEC during explorative surgery: risk factors, treatment options, and prognosis. Annals of surgical oncology. 2015;22(4):1236–1242.
Kusamura S, Moran BJ, Sugarbaker PH, et al. Multicentre study of the learning curve and surgical performance of cytoreductive surgery with intraperitoneal chemotherapy for pseudomyxoma peritonei. The British journal of surgery. 2014;101(13):1758–1765.
Guerrero W, Munene G, Dickson PV, et al. Outcome and factors associated with aborted cytoreduction for peritoneal carcinomatosis. Journal of gastrointestinal oncology. 2018;9(4):664–673.
Polanco PM, Ding Y, Knox JM, et al. Institutional learning curve of cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion for peritoneal malignancies. Annals of surgical oncology. 2015;22(5):1673–1679.
Paul BK, Ihemelandu C, Sugarbaker PH. Prior Surgical Score: An Analysis of the Prognostic Significance of an Initial Nondefinitive Surgical Intervention in Patients With Peritoneal Carcinomatosis of a Colorectal Origin Undergoing Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy. Diseases of the colon and rectum. 2018;61(3):347–354.
Kusamura S, Hutanu I, Baratti D, Deraco M. Circulating tumor markers: predictors of incomplete cytoreduction and powerful determinants of outcome in pseudomyxoma peritonei. Journal of surgical oncology. 2013;108(1):1–8.
Canbay E, Ishibashi H, Sako S, et al. Preoperative carcinoembryonic antigen level predicts prognosis in patients with pseudomyxoma peritonei treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. World J Surg. 2013;37(6):1271–1276.
Tan GH, Novo CA, Dayal S, et al. The modified Glasgow prognosis score predicts for overall and disease-free survival following cytoreductive surgery and HIPEC in patients with pseudomyxoma peritonei of appendiceal origin. European journal of surgical oncology. 2017;43(2):388–394.
Chua TC, Chong CH, Liauw W, Zhao J, Morris DL. Inflammatory markers in blood and serum tumor markers predict survival in patients with epithelial appendiceal neoplasms undergoing surgical cytoreduction and intraperitoneal chemotherapy. Annals of surgery. 2012;256(2):342–349.
Carr NJ, Bibeau F, Bradley RF, et al. The histopathological classification, diagnosis and differential diagnosis of mucinous appendiceal neoplasms, appendiceal adenocarcinomas and pseudomyxoma peritonei. Histopathology. 2017;71(6):847–858.
Munoz-Zuluaga C, Sardi A, King MC, et al. Outcomes in Peritoneal Dissemination from Signet Ring Cell Carcinoma of the Appendix Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Annals of surgical oncology. 2019;26(2):473–481.
Carr NJ, Finch J, Ilesley IC, et al. Pathology and prognosis in pseudomyxoma peritonei: a review of 274 cases. Journal of clinical pathology. 2012;65(10):919–923.
Chua TC, Moran BJ, Sugarbaker PH, et al. 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. Journal of clinical oncology. 2012;30(20):2449–2456.
Shetty S, Natarajan B, Thomas P, Govindarajan V, Sharma P, Loggie B. Proposed classification of pseudomyxoma peritonei: influence of signet ring cells on survival. The American surgeon. 2013;79(11):1171–1176.
Jarvinen P, Ristimaki A, Kantonen J, Lepisto A. Feasibility of radical cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for pseudomyxoma peritonei of appendiceal origin. Scandinavian journal of surgery. 2013;102(3):145–151.
Milovanov V, Sardi A, Aydin N, Nieroda C, Sittig M, Gushchin V. External Validation of the Simplified Preoperative Assessment for Low-Grade Mucinous Adenocarcinoma of the Appendix. Annals of surgical oncology. 2017;24(7):1783–1786.
Rivard JD, Temple WJ, McConnell YJ, Sultan H, Mack LA. Preoperative computed tomography does not predict resectability in peritoneal carcinomatosis. American journal of surgery. 2014;207(5):760–764; discussion 764–765.
Chua TC, Al-Zahrani A, Saxena A, et al. Determining the association between preoperative computed tomography findings and postoperative outcomes after cytoreductive surgery and perioperative intraperitoneal chemotherapy for pseudomyxoma peritonei. Annals of surgical oncology. 2011;18(6):1582–1589.
Iversen LH, Rasmussen PC, Laurberg S. Value of laparoscopy before cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis. The British journal of surgery. 2013;100(2):285–292.
Kozman MA, Fisher OM, Rebolledo BJ, et al. CA 19-9 to peritoneal carcinomatosis index (PCI) ratio is prognostic in patients with epithelial appendiceal mucinous neoplasms and peritoneal dissemination undergoing cytoreduction surgery and intraperitoneal chemotherapy: A retrospective cohort study. European journal of surgical oncology. 2017;43(12):2299–2307.
Lohani K, Shetty S, Sharma P, Govindarajan V, Thomas P, Loggie B. Pseudomyxoma peritonei: inflammatory responses in the peritoneal microenvironment. Annals of surgical oncology. 2014;21(5):1441–1447.
Miner TJ, Shia J, Jaques DP, Klimstra DS, Brennan MF, Coit DG. Long-term survival following treatment of pseudomyxoma peritonei: an analysis of surgical therapy. Annals of surgery. 2005;241(2):300–308.
The authors thank Ryan MacDonald, Ph.D., for helpful discussions during the statistical analysis of this study.
Ekaterina Baron, Vladimir Milovanov, Michelle Sittig, Carol Nieroda, Vadim Gushchin, and Armando Sardi declare there are no conflicts of interest regarding the publication of this paper.
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Baron, E., Milovanov, V., Gushchin, V. et al. Predicting Aborted Hyperthermic Intraperitoneal Chemotherapy (AHIPEC) with Preoperative Tumor and Inflammatory Markers in Potentially Resectable Appendiceal Cancer Patients with Peritoneal Carcinomatosis. Ann Surg Oncol 27, 2548–2556 (2020). https://doi.org/10.1245/s10434-019-08117-w