Third look surgery and beyond for appendiceal malignancy with peritoneal dissemination

Background and Objectives: Second look surgery has been previously studied in patients with recurrent peritoneal dissemination from appendiceal malignancy. However, selection criteria for third, fourth, and subsequent reoperations are not available. Methods: Five hundred and one patients with epithelial peritoneal surface malignancy of appendiceal origin underwent treatment with cytoreductive surgery and intraperitoneal chemotherapy during an 18-year period. Forty-five of these patients (8.9%) underwent three or more operative interventions. A critical statistical analysis of the impact of selected clinical features on survival was performed from a prospective database. Results: Overall 5-year survival of these 45 patients was 70%. Five- and ten-year survival rates for patients with three interventions were 60 and 48%, for four interventions were 78 and 36%, and for five or more interventions were 100 and 80%. Sites of recurrent disease, histopathologic type of tumor, and lymph node status had no impact on survival. A complete second and third cytoreduction was associated with an improved 5-year survival rate. Conclusions: Prolonged survival in patients with three or more reoperations was significantly associated with a complete cytoreduction. However, after four or more interventions, the effects of tumor biology may predominate. Although 5-year survival is likely with multiple reoperations, prolonged follow-up shows that cancer cure is a rare event.