Should We Be Doing Cytoreductive Surgery with HIPEC for Signet Ring Cell Appendiceal Adenocarcinoma? A Study from the US HIPEC Collaborative

Nick C. Levinsky, Mackenzie C. Morris, Koffi Wima, Jeffrey J. Sussman, Syed A. Ahmad, Jordan M. Cloyd, Charles Kimbrough, Keith Fournier, Andrew Lee, Sean Dineen, Sophie Dessureault, Jula Veerapong, Joel M. Baumgartner, Callisia Clarke, Mohammad Y. Zaidi, Charles A. Staley, Shishir K. Maithel, Jennifer Leiting, Travis Grotz, Laura LambertRyan J. Hendrix, Sean Ronnekleiv-Kelly, Courtney Pokrzywa, Mustafa Raoof, Oliver S. Eng, Fabian M. Johnston, Jonathan Greer, Sameer H. Patel

Research output: Contribution to journalArticlepeer-review

6 Scopus citations


Background: Appendiceal adenocarcinoma with signet ring cells (SCA) is associated with worse overall survival (OS), and it is unclear whether cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) should be pursued in this patient population. We assessed the prognostic implications of signet ring cells in patients with appendiceal adenocarcinoma and peritoneal carcinomatosis undergoing CRS-HIPEC. Methods: The US HIPEC Collaborative, a 12-center, multi-institutional database of patients undergoing CRS-HIPEC, was reviewed for patients with SCA. Univariate and multivariate analyses were performed. Results: Of 514 patients undergoing CRS-HIPEC for appendiceal adenocarcinoma, 125 (24%) had SCA. The SCA and non-SCA groups had similar baseline characteristics. SCA had worse OS compared with non-SCA (32.0 vs 91.4 months, p < 0.001). In univariate analysis for only SCA cases, there was worse OS in patients with poorly differentiated tumors, positive lymph nodes, LVI, PCI > 20, or incomplete cytoreduction (CC-2/3). However, multivariate analysis showed only positive lymph nodes (HR 1.14 [95% CI 1.00–1.31], p = 0.04), poor differentiation (5.60 [1.29–24.39], p = 0.02), and incomplete cytoreduction (4.90 [1.11–12.70], p = 0.03) were independently associated with decreased OS for SCA. Conclusion: While signet cells are a negative prognostic feature, they should not be a contraindication to CRS-HIPEC in patients with well-moderately differentiated tumors with negative lymph nodes, where complete cytoreduction can be achieved.

Original languageEnglish (US)
Pages (from-to)155-164
Number of pages10
JournalJournal of Gastrointestinal Surgery
Issue number1
StatePublished - Jan 1 2020


  • Appendiceal adenocarcinoma
  • Cytoreductive surgery
  • Hyperthermic intraperitoneal chemotherapy
  • Signet ring cells

ASJC Scopus subject areas

  • Surgery
  • Gastroenterology


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