title: Oncologic Risk Stratification Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Appendiceal Carcinomatosis.
abstract: BACKGROUND
  Patients with peritoneal carcinomatosis (PC) of appendiceal origin demonstrate variable oncologic outcomes, despite aggressive cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). We sought to devise a prognostic risk stratification system for oncologic outcomes following CRS-HIPEC.
  
  
  METHODS
  A total of 197 patients undergoing CRS-HIPEC for the treatment of appendiceal PC were reviewed from a prospective database. Kaplan-Meier survival curves and multivariate Cox regression models were used to identify prognostic factors affecting oncologic outcomes. Clinicopathologic variables affecting overall survival (OS) were utilized to develop a prognostic staging system and nomograms.
  
  
  RESULTS
  Univariate and multivariate Cox regression analysis indicated that high-grade tumor histology, lymph node metastasis, and incomplete cytoreduction were high-risk features, adversely affecting OS. Patients were stratified on the presence of high-risk features as follows: low-risk patients had no risk factors (n = 102); intermediate-risk patients had one risk factor (n = 49); and high-risk patients had more than one risk factor (n = 46). Median OS for low-risk patients was not reached, and was 43 and 22 months for intermediate-risk and high-risk patients, respectively. Five-year OS was 72, 43, and 13 % for low-, intermediate- and high-risk patients, respectively (p < 0.0003 for low vs. intermediate risk, and p = 0.06 for intermediate vs. high risk).
  
  
  CONCLUSIONS
  We propose a three-tier staging system for appendiceal PC following CRS-HIPEC, based on histologic grade, lymph node involvement, and completeness of cytoreduction. The presence of any one or more of these high-risk features significantly decreased survival in our single-institution database and provided the basis for a prognostic staging system and corresponding nomograms.
authors.affiliation: Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
authors.forename: Patrick L
authors.initials: PL
authors.lastname: Wagner
authors.affiliation: Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
authors.forename: Frances
authors.initials: F
authors.lastname: Austin
authors.affiliation: Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
authors.forename: Mazen
authors.initials: M
authors.lastname: Zenati
authors.affiliation: Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
authors.forename: Aaron
authors.initials: A
authors.lastname: Jaech
authors.affiliation: Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
authors.forename: Arun
authors.initials: A
authors.lastname: Mavanur
authors.affiliation: Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
authors.forename: Lekshmi
authors.initials: L
authors.lastname: Ramalingam
authors.affiliation: Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
authors.forename: Heather L
authors.initials: HL
authors.lastname: Jones
authors.affiliation: Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
authors.forename: Matthew P
authors.initials: MP
authors.lastname: Holtzman
authors.affiliation: Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
authors.forename: Steven A
authors.initials: SA
authors.lastname: Ahrendt
authors.affiliation: Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
authors.forename: Amer H
authors.initials: AH
authors.lastname: Zureikat
authors.affiliation: Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
authors.forename: James F
authors.initials: JF
authors.lastname: Pingpank
authors.affiliation: Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
authors.forename: Herbert J
authors.initials: HJ
authors.lastname: Zeh
authors.affiliation: Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
authors.forename: David L
authors.initials: DL
authors.lastname: Bartlett
authors.affiliation: Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA. choudrymh@upmc.edu.
authors.forename: Haroon A
authors.initials: HA
authors.lastname: Choudry
mesh_terms: D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D001063:Appendiceal Neoplasms / Q000473:pathology* / Q000628:therapy; D010478:Chemotherapy, Cancer, Regional Perfusion; D003131:Combined Modality Therapy; D065426:Cytoreduction Surgical Procedures; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006979:Hyperthermia, Induced; D007274:Injections, Intraperitoneal; D053208:Kaplan-Meier Estimate; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D010534:Peritoneal Neoplasms / Q000556:secondary* / Q000628:therapy; D011379:Prognosis; D011446:Prospective Studies; D018570:Risk Assessment; D015996:Survival Rate