Delivered by Publishing Technology to: University of Wisconsin-Madison IP: 144.92.202.36 on: Thu, 06 Dec 2012 14:05:23 Copyright Southeastern Surgical Congress. All rights reserved. Right Hemicolectomy Is Not Routinely Indicated in Pseudomyxoma Peritonei JASON M. FOSTER, M.D.,*† PRATEEK K. GUPTA, M.D.,* JOSEPH H. CARREAU, M.D.,* TRAVIS E. GROTZ, M.D.,* JOSEPH V. BLAS, M.D.,* ZORAN GATALICA, M.D.,‡ SWAPAN NATH, PH.D.,§ BRIAN W. LOGGIE, M.D.* From the *Department of Surgery, Creighton Cancer Center, Creighton University, Omaha, Nebraska; the †Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska; the ‡Department of Pathology, Creighton University, Omaha, Nebraska; and the §Department of Arthritis and Immunology, Oklahoma University, Oklahoma City, Oklahoma Pseudomyxoma peritonei (PMP) is primarily the result of a ruptured mucinous appendix neo- plasm (MAN). Often MAN is lumped with but biologically distinct from intestinal appendiceal adenocarcinoma. Nodal and systemic dissemination are rare with the peritoneal cavity being the primary site of recurrence. Routine performance of right hemicolectomy (RHC) for PMP/MAN has been extensively debated without consensus. Our objective was to ascertain whether RHC has a survival advantage over appendectomy. We hypothesize if RHC is mandatory, then increased tumor recurrence and mortality should be observed in appendectomy only. Retrospective chart review was carried out in patients with tumors that met the Ronnett classification for PMP/MAN. Demographics, tumor grade, extent, recurrence, and progression were recorded. We report the rate of nodal involvement/recurrence in patients treated with RHC versus appendectomy as well as the rate of systemic and peritoneal recurrence and survival. Multivariate logistic regression was done to identify factors that impact survival. Of 120 patients, 48 had appendectomy and 72 had RHC. Seven per cent of patients undergoing RHC had positive lymph nodes and no nodal failures (0%) in patients undergoing appendectomy. Appendectomy versus RHC recurrence rates (21 vs. 28%, P 5 0.12) and death resulting from disease (8 vs. 22%, P 5 0.27) were similar. Logistic regression revealed that the type of surgery had no impact on recurrence and mortality, only optimal resection score and performance status. There was no difference in tumor recurrence or survival based on treatment by appendectomy or RHC. Performance status and complete cytoreduction are the only factors associated with survival. Lymph node involvement is rare and selective RHC is safe in PMP/MAN. A PPENDICEAL NEOPLASMS PRESENT with a wide variety of histological variants, including carcinoid, goblet cell (adenocarcinoid), signet ring cell, intestinal epithelial type, and mucinous tumors. The reported incidence of these tumors found in appendectomy specimens ranges from 0.01 to 3 per cent, accounting for 1 per cent of gastrointestinal malignancies. 1, 2 Given the anatomic structure of the appendix, perforation is common with appendiceal cancers and is the primary mechanism of peritoneal dissemination. Mucinous appendiceal neo- plasms (MANs) represent a distinct subtype of ap- pendix tumors that on dissemination in the peritoneal cavity result in the condition pseudomyxoma peritonei (PMP). PMP is a unique malignant process in which mucin is the primary histopathologic (pathognomonic) component associated with variable amounts of tumor cellularity. When PMP is not treated, progression of the disease results in bowel obstruction, fistula, pain, cachexia, and death. 3, 4 Unlike nonmucinous epithelial cancers of the large bowel and appendix, MANs rarely spread systemically and the incidence of nodal involvement is not well documented. The few studies that have explored lymph node status in MAN have reported it to range from 4 to 10 per cent. 2, 5 This node positivity rate is significantly lower than the 25 to 50 per cent incidence of node- positive disease reported in nonmucinous epithelial appendix and colon carcinoma. 6, 7 Historically, MAN tumors have been treated with right hemicolectomy (RHC), but there is a paucity of data that has explored the benefit of routine RHC in PMP/MAN. Gonzalez- Moreno et al. reported that patients with MAN treated with appendectomy alone did not experience any survival Presented at the Southeastern Surgical Congress, February 21– 22, 2010, Savannah, GA. Address correspondence and reprint requests to Jason M. Foster, M.D., Associate Professor of Surgery, Division of Surgical Oncology, University of Nebraska Medical Center, 984030 Nebraska Medical Center, Omaha, NE 68198-4030. E-mail: jfosterm@unmc.edu. 171