Kevin M Turner1, Mackenzie C Morris1, Aaron M Delman1, Dennis Hanseman1, Fabian M Johnston2, Jonathan Greer2, Kara Vande Walle3, Daniel E Abbott3, Mustafa Raoof4, Travis E Grotz5, Keith Fournier6, Sean Dineen7, Jula Veerapong8, Ugwuji Maduekwe9, Anai Kothari9, Charles A Staley10, Shishir K Maithel10, Laura A Lambert11, Alex C Kim12, Jordan M Cloyd12, Gregory C Wilson13, Jeffrey J Sussman13, Syed A Ahmad13, Sameer H Patel14. 1. Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA. 2. Department of Surgery, Johns Hopkins University, Baltimore, MD, USA. 3. Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, WI, USA. 4. Department of Surgery, Division of Surgical Oncology, City of Hope National Medical Center, Duarte, CA, USA. 5. Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA. 6. Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA. 7. Department of Gastrointestinal Oncology, Moffitt Cancer Center, Morsani College of Medicine, Tampa, FL, USA. 8. Department of Surgery, Division of Surgical Oncology, University of California, San Diego, San Diego, CA, USA. 9. Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI, USA. 10. Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA. 11. Peritoneal Surface Malignancy Program Section of Surgical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA. 12. Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA. 13. Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Medical Science Building, 231 Albert Sabin Way, Cincinnati, OH, 45267-0558, USA. 14. Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Medical Science Building, 231 Albert Sabin Way, Cincinnati, OH, 45267-0558, USA. patel5se@ucmail.uc.edu.
Abstract
BACKGROUND: Whether formal regional lymph node (LN) evaluation is necessary for patients with appendiceal adenocarcinoma (AA) who have peritoneal metastases is unclear. The aim of this study was to evaluate the prognostic value of LN metastases on survival in patients treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). METHODS: A retrospective analysis of the US HIPEC collaborative, a multi-institutional consortium comprising 12 high-volume centers, was performed to identify patients with AA who underwent CRS-HIPEC with adequate LN sampling (≥ 12 LNs). RESULTS: Two hundred-fifty patients with AA who underwent CRS-HIPEC were included. Outcomes were compared between LN - and LN + disease. Baseline patient characteristics between groups were similar, with most patients undergoing complete cytoreduction (0/1: 86.0% vs. 76.8%, p = 0.08), respectively. More adverse tumor factors were found in patients with LN + disease, including poor differentiation, signet ring cells, and lymphovascular invasion. Multivariate analysis of overall survival (OS) found LN + disease was independently associated with worse OS (HR: 2.82 95%CI: 1.25-6.34, p = 0.01), even after correction for receipt of systemic therapy. On Kaplan-Meier analysis, median OS was lower in patients with LN + disease (25.9 months vs. 91.4 months, p < 0.01). LN + disease remained associated with poor OS following propensity score matching (HR: 4.98 95%CI: 1.72-14.40, p < 0.01) and in patients with PCI ≥ 20 (HR: 3.68 95%CI: 1.54-8.80, p < 0.01). CONCLUSIONS: In this large multi-institutional study of patients with AA undergoing CRS-HIPEC, LN status remained associated with worse OS even in the setting of advanced peritoneal carcinomatosis. Formal LN evaluation should be performed for most patients with AA undergoing CRS-HIPEC.
BACKGROUND: Whether formal regional lymph node (LN) evaluation is necessary for patients with appendiceal adenocarcinoma (AA) who have peritoneal metastases is unclear. The aim of this study was to evaluate the prognostic value of LN metastases on survival in patients treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). METHODS: A retrospective analysis of the US HIPEC collaborative, a multi-institutional consortium comprising 12 high-volume centers, was performed to identify patients with AA who underwent CRS-HIPEC with adequate LN sampling (≥ 12 LNs). RESULTS: Two hundred-fifty patients with AA who underwent CRS-HIPEC were included. Outcomes were compared between LN - and LN + disease. Baseline patient characteristics between groups were similar, with most patients undergoing complete cytoreduction (0/1: 86.0% vs. 76.8%, p = 0.08), respectively. More adverse tumor factors were found in patients with LN + disease, including poor differentiation, signet ring cells, and lymphovascular invasion. Multivariate analysis of overall survival (OS) found LN + disease was independently associated with worse OS (HR: 2.82 95%CI: 1.25-6.34, p = 0.01), even after correction for receipt of systemic therapy. On Kaplan-Meier analysis, median OS was lower in patients with LN + disease (25.9 months vs. 91.4 months, p < 0.01). LN + disease remained associated with poor OS following propensity score matching (HR: 4.98 95%CI: 1.72-14.40, p < 0.01) and in patients with PCI ≥ 20 (HR: 3.68 95%CI: 1.54-8.80, p < 0.01). CONCLUSIONS: In this large multi-institutional study of patients with AA undergoing CRS-HIPEC, LN status remained associated with worse OS even in the setting of advanced peritoneal carcinomatosis. Formal LN evaluation should be performed for most patients with AA undergoing CRS-HIPEC.
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