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. 2015 Oct;22(11):3640-6.
doi: 10.1245/s10434-015-4446-y. Epub 2015 Feb 20.

A Simplified Preoperative Assessment Predicts Complete Cytoreduction and Outcomes in Patients with Low-Grade Mucinous Adenocarcinoma of the Appendix

Sean P Dineen  1 , Richard E Royal  2 , Marybeth S Hughes  3 , Tara Sagebiel  4 , Priya Bhosale  4 , Michael Overman  5 , Aurelio Matamoros  4 , Paul F Mansfield  2 , Keith F Fournier  2
Affiliations

A Simplified Preoperative Assessment Predicts Complete Cytoreduction and Outcomes in Patients with Low-Grade Mucinous Adenocarcinoma of the Appendix

Sean P Dineen et al. Ann Surg Oncol. 2015 Oct.

Abstract

Background: Complete cytoreduction with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) has been shown to improve survival in patients with low-grade mucinous adenocarcinoma (LGMA). However, incomplete cytoreduction exposes patients to significant morbidity without a similar survival benefit. Preoperative assessment of the ability to achieve CRS is therefore a critical step in selecting patients for CRS/HIPEC.

Objective: The aim of this study was to develop and validate a preoperative scoring system to accurately predict the ability to achieve complete cytoreduction in patients with LGMA of the appendix.

Methods: A simplified preoperative assessment for appendix tumor (SPAAT) score was developed based on computed tomography scan findings thought to predict incomplete cytoreduction. We applied the SPAAT score to patients with LGMA to determine the ability of the score to predict complete cytoreduction. This scoring system was then applied to a separate cohort of patients from a different institution. Sensitivity and specificity were determined for the SPAAT score. Survival was calculated and correlated with the SPAAT score and the completeness of cytoreduction score.

Results: A SPAAT score of <3 is a significant predictor of complete cytoreduction in the derivation cohort. In the validation cohort, 40 of 42 patients with a SPAAT score <3 achieved a complete cytoreduction, for a positive predictive value of 95.2 % and a negative predictive value of 100 %. Additionally, the SPAAT score was a significant predictor of disease-free survival.

Conclusions: The SPAAT score is a useful tool in the preoperative assessment of patients with LGMA who are under consideration for cytoreductive surgery. Prospective analysis of this scoring system is warranted to appropriately select patients who will benefit from CRS/HIPEC.

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Figures

Fig. 1
Fig. 1
SPAAT scoring of visceral organs. a Mucinous ascites around the liver and spleen; however, the border is smooth without evidence of scalloping and this would be assigned zero points. b Mucinous ascites with a smooth spleen and pancreas border. Again, zero points are assigned. c CT scan findings of scalloping of the liver (arrow). d Liver and spleen scalloping (arrows). e Loss of the smooth pancreatic border with indentation of the organ (arrow), representing a CT finding that would score one point. SPAAT simplified preoperative assessment for appendix tumor, CT computed tomography
Fig. 2
Fig. 2
SPAAT scoring of the small bowel. Panel a demonstrates a patient with a significant amount of mucinous ascites, but the small bowel still appears to be floating freely. This would be assigned a zero for the SPAAT score. However, in panel b the patient demonstrates tethering of the small bowel, and would be given 3 points in the SPAAT system. SPAAT simplified preoperative assessment for appendix tumor
Fig. 3
Fig. 3
Distribution of SPAAT scores in the validation cohort (n = 70). Scores in the validation cohort ranged from 0 to 7. Overall, 42 patients (60 %) demonstrated an SPAAT score <3, and 28 (40 %) had scores ≥3. SPAAT simplified preoperative assessment for appendix tumor
Fig. 4
Fig. 4
Complete cytoreduction is associated with improved OS and DFS. a OS is significantly higher in patients with complete cytoreduction compared with those with incomplete cytoreduction. b Patients with SPAAT scores <3 demonstrated improved OS compared with those with an SPAAT score ≥3; however, this did not reach statistical significance. c DFS was compared in the validation cohort between patients with a complete cytoreduction and those without. The median DFS was significantly longer in patients with CCR0/1 resection (p < 0.001). d DFS for patients based on SPAAT score. The survival curves for patients with CCR1/2 resection are nearly identical to those with an SPAAT score <3. CCR completeness of cytoreduction, DFS disease-free survival, OS overall survival, SPAAT simplified preoperative assessment for appendix tumor
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References

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