Preoperative Radiographic Assessment Predicts Incomplete Cytoreduction in Patients with Low Grade Mucinous Adenocarcinoma of the Appendix

Ann Surg Oncol. 2020 Jan;27(1):165-170. doi: 10.1245/s10434-019-07676-2. Epub 2019 Aug 6.


Background: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) for patients with low-grade mucinous adenocarcinoma (LGMA) is most effective when complete cytoreduction is achieved. We externally validated two radiographic scoring systems to predict resectability and assessed radiographic response to systemic chemotherapy (SCT).

Methods: Patients with LGMA who received preoperative SCT followed by CRS/HIPEC from 2013 to 2016 were identified. CT scans were graded by six physicians using the simplified radiologic score (SRS) and simplified preoperative assessment of appendiceal tumor (SPAAT) systems. Positive and negative predictive values (PPV, NPV) were calculated by comparing to completeness of cytoreduction. Inter-rater agreement was assessed using the intraclass correlation coefficient (ICC).

Results: Twenty-four patients had preoperative SCT followed by CRS/HIPEC. Thirteen patients underwent incomplete CRS and 11 patients complete CRS. Scoring of the preoperative CT had a PPV of complete cytoreduction of 75% and 66.7% for SRS and SPAAT, respectively. NPV was 83.4% and 88.9% for SRS and SPAAT, respectively. ICC for the preoperative SRS and SPAAT score was 0.826 (95% confidence interval [CI]: 0.720-0.910] and 0.788 [0.667-0.888). Comparison of CT scans before and after SCT recorded an increase in calculated scores in 45.8% (SRS) and 50% (SPAAT) of patients.

Conclusions: External validation of two radiographic scoring systems to predict complete cytoreduction showed that inter-rater agreement for both systems was good. Both scoring systems predicted incomplete cytoreduction. Applying a systematic approach to preoperative imaging review is recommended to improve treatment selection by minimizing morbidity associated with incomplete CRS and help to set patient expectations.

Publication types

  • Validation Study

MeSH terms

  • Adenocarcinoma, Mucinous / diagnostic imaging*
  • Adenocarcinoma, Mucinous / therapy
  • Adult
  • Aged
  • Antineoplastic Agents / therapeutic use
  • Appendiceal Neoplasms / diagnostic imaging*
  • Appendiceal Neoplasms / therapy
  • Cohort Studies
  • Combined Modality Therapy
  • Cytoreduction Surgical Procedures*
  • Female
  • Humans
  • Hyperthermia, Induced*
  • Male
  • Middle Aged
  • Neoplasm Grading
  • Predictive Value of Tests
  • Preoperative Care / standards*
  • Prognosis
  • Retrospective Studies
  • Tomography, X-Ray Computed / standards


  • Antineoplastic Agents