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Validation of the AJCC 8th Edition Staging System for Disseminated Appendiceal Cancer Patients Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: A Multi-institutional Analysis

  • Peritoneal Surface Malignancy
  • Published:
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Abstract

Background

The AJCC 8th edition stratifies stage IV disseminated appendiceal cancer (dAC) patients based on grade and pathology. This study was designed to externally validate the staging system and to identify predictors of long-term survival.

Methods

A 12-institution cohort of dAC patients treated with CRS ± HIPEC was retrospectively analyzed. Overall survival (OS) and recurrence-free survival (RFS) were analyzed by using Kaplan-Meier and log-rank tests. Univariate and multivariate cox-regression was performed to assess factors associated with OS and RFS.

Results

Among 1009 patients, 708 had stage IVA and 301 had stage IVB disease. Median OS (120.4 mo vs. 47.2 mo) and RFS (79.3 mo vs. 19.8 mo) was significantly higher in stage IVA compared with IVB patients (p < 0.0001). RFS was greater among IVA-M1a (acellular mucin only) than IV M1b/G1 (well-differentiated cellular dissemination) patients (NR vs. 64 mo, p = 0.0004). Survival significantly differed between mucinous and nonmucinous tumors (OS 106.1 mo vs. 41.0 mo; RFS 46.7 mo vs. 21.2 mo, p < 0.05), and OS differed between well, moderate, and poorly differentiated (120.4 mo vs. 56.3 mo vs. 32.9 mo, p < 0.05). Both stage and grade were independent predictors of OS and RFS on multivariate analysis. Acellular mucin and mucinous histology were associated with better OS and RFS on univariate analysis only.

Conclusions

AJCC 8th edition performed well in predicting outcomes in this large cohort of dAC patients treated with CRS ± HIPEC. Separation of stage IVA patients based on the presence of acellular mucin improved prognostication, which may inform treatment and long-term, follow-up strategies.

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Data Availability

It is the policy of the United States HIPEC Collaborative that the data compiled in the multi-institutional database are not to be shared.

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Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author information

Authors and Affiliations

  1. Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA

    Gopika SenthilKumar BS, Anai N. Kothari MD, MS & Ugwuji N. Maduekwe MD

  2. Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Keith Fournier MD & Andrew Lee MD, PhD

  3. Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA

    Daniel E. Abbott MD

  4. Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA

    Gregory C. Wilson MD & Sameer H. Patel MD

  5. Department of Surgery, Johns Hopkins University, Baltimore, MD, USA

    Jonathan Greer MD & Fabian Johnston MD, MHS

  6. Department of Gastrointestinal Oncology, Moffitt Cancer Center, and Department of Oncologic Sciences, Morsani College of Medicine, Tampa, FL, USA

    Sean P. Dineen MD & Benjamin D. Powers MD, MS

  7. Division of Surgical Oncology, Department of Surgery, University of California, San Diego, CA, USA

    Joel Baumgartner MD & Jula Veerapong MD

  8. Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA

    Jennifer Leiting MD & Travis E. Grotz MD

  9. Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA

    Shishir K. Maithel MD & Charles Staley MD

  10. Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA

    Mustafa Raoof MD

  11. Department of Surgery, University of Utah Huntsman Cancer Institute, Salt Lake City, UT, USA

    Laura Lambert MD

  12. Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA

    Alex Kim MD, PhD & Jordan M. Cloyd MD

  13. Department of Surgery, University of Washington Medical Center, Seattle, WA, USA

    Harveshp Mogal MD

Authors
  1. Gopika SenthilKumar BS
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  2. Anai N. Kothari MD, MS
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  3. Ugwuji N. Maduekwe MD
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  4. Keith Fournier MD
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  12. Joel Baumgartner MD
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  13. Jula Veerapong MD
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  14. Jennifer Leiting MD
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  15. Travis E. Grotz MD
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  16. Shishir K. Maithel MD
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  17. Charles Staley MD
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  18. Mustafa Raoof MD
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  19. Laura Lambert MD
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  20. Andrew Lee MD, PhD
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  21. Alex Kim MD, PhD
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  22. Jordan M. Cloyd MD
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  23. Harveshp Mogal MD
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Correspondence to Harveshp Mogal MD.

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10434_2023_13697_MOESM1_ESM.pdf

Supplemental Fig. 1 Kaplan-Meier curves of (A) overall survival and (B) recurrence-free survival of patients treated with CRS ± HIPEC with mucinous vs. nonmucinous tumors (PDF 225 KB)

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SenthilKumar, G., Kothari, A.N., Maduekwe, U.N. et al. Validation of the AJCC 8th Edition Staging System for Disseminated Appendiceal Cancer Patients Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: A Multi-institutional Analysis. Ann Surg Oncol 30, 5743–5753 (2023). https://doi.org/10.1245/s10434-023-13697-9

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