Appendix cancer medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Soroush Seifirad, M.D.[2]
Overview
Medical therapy in appendix cancer could be either supportive, palliative, or curative. While carcinoid tumors rarely need chemotherapy, systemic chemotherapy as well as hyperthermic intraperitoneal chemotherapy plus/minus early postoperative intraperitoneal chemotherapy (EPIC) and/or concomitant intravenous chemotherapy are mainstream of medical treatment in adenocarcinoma of appendix. Medical therapy is generally administered to control the symptoms in patients with carcinoid tumors and carcinoid syndrome.
Medical Therapy
- Somatostatin analogs
- Loperamide or diphenoxylate for primary diarrhea
- Somatostatin analogs for symptom control in patients with carcinoid syndrome.
- Curative and palliative chemotherapy
- Systemic chemotherapy
- Systemic chemotherapy has not been generally recommended for carcionid tumors, but patients with non-cacinoid tumors are usually receive chemotherapy.
- Nevertheless systemic chemotherapy for metastatic appendiceal adenocarcinoma has not been studied appropriately.
- Many experts refer to current colorectal cancer chemotherapy approaches for adenocarcinoma of appendix.
- Current colon cancer chemotherapy agents are as follows:
- 5-fluorouracil (5-FU) : Traditional active agent
- Irinotecan
- Oxaliplatin
- Vascular endothelial growth factor receptor inhibitors (bevacizumab)
- Epidermal growth factor receptor inhibitors (cetuximab and panitumumab),
- Aflibercept
- Regorafenib: inhibitor of angiogenic tyrosine kinases (including the VEGF receptors 1,2, and 3),
- Capecitabine or 5-FU with or without a platinum drug
- FOLFOX-6 has been widely recommended in patients with appendix adenocarcinoma.
- Oxaliplatin, 5-FU and leucovorin or capecitabine are active agents of the FOLFOX regime. <math>\blacktriangledown</math>
| Modified FOLFOX-6[4][5] |
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- Cycle length is 14 days
- Doses should be recalculated if there is a 10 percent or more change in body weight.
- Prior to each treatment<math>\blacktriangledown</math>
- Assess changes in neurologic function.
- Assess electrolytes and liver and renal function.
- CBC with differential and platelet count.
- Common complications and approaches to complications
- Diarrhea:
- Grade 2 or worse diarrhea: <math>\blacktriangledown</math>
- Withhold treatment.
- Restart at a lower dose of FU after complete resolution.
- Severe diarrhea, mucositis, and myelosuppression after FU:<math>\blacktriangledown</math>
- Evaluate for dihydropyrimidine dehydrogenase deficiency.
- Grade 2 or worse diarrhea: <math>\blacktriangledown</math>
- Neurologic toxicity
- In order to decrease chance of developing oxaliplatin induced neuropathy recommend patients to avoid exposure to cold up to 48 hours after each infusion.
- Transient grade 3 paresthesia/dysesthesia / grade 2 symptoms lasting longer than 1 week:<math>\blacktriangledown</math>
- Decrease oxaliplatin dose by 25 percent.
- Grade 4 or persistent grade 3 paresthesia/dysesthesia:<math>\blacktriangledown</math>
- Discontinue oxaliplatin.
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- Total white blood cell count <3000 cells/mm 3 , absolute neutrophil count <1500 cells/mm 3 , or platelets <100,000 /mm 3 on the day of treatment:<math>\blacktriangledown</math>
- Delay treatment cycle by one week.
- If treatment is delayed for two weeks or delayed for one week on two separate occasions, eliminate FU bolus.
- If occurred again:<math>\blacktriangledown</math>
- Reduce infusional 5-FU by 20 percent and
- Reduce oxaliplatin dose from 65 mg/m 2
- Total white blood cell count <3000 cells/mm 3 , absolute neutrophil count <1500 cells/mm 3 , or platelets <100,000 /mm 3 on the day of treatment:<math>\blacktriangledown</math>
- Delivered in the operating room after cytoreductive surgery.
- In selected cases is accompanied by early postoperative intraperitoneal chemotherapy (EPIC) as well as concomitant intravenous chemotherapy (CIVC).
| Common HIPEC current regimens |
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- Infuse the fluid at 43-45°Ci n order to maintain the intraperitoneal fluid temperature at 41-43°C.
- To avoid renal toxicity maintain urine output higher than 100 cc (desirable 150 cc) every 15 min during HIPEC.
References
- ↑ Moertel CG, Weiland LH, Nagorney DM, Dockerty MB (1987). "Carcinoid tumor of the appendix: treatment and prognosis". N. Engl. J. Med. 317 (27): 1699–701. doi:10.1056/NEJM198712313172704. PMID 3696178.
- ↑ Treatment Option Overview for GI Carcinoid Tumors . NATIONAL CANCER INSTITUTE . http://www.cancer.gov/types/gi-carcinoid-tumors/hp/gi-carcinoid-treatment-pdq#link/_97_toc Accessed on September 22, 2015
- ↑ 3.0 3.1 González-Moreno S, González-Bayón LA, Ortega-Pérez G (2010) Hyperthermic intraperitoneal chemotherapy: Rationale and technique. World J Gastrointest Oncol 2 (2):68-75. DOI:10.4251/wjgo.v2.i2.68 PMID: 21160924
- ↑ Cheeseman SL, Joel SP, Chester JD, Wilson G, Dent JT, Richards FJ et al. (2002) A 'modified de Gramont' regimen of fluorouracil, alone and with oxaliplatin, for advanced colorectal cancer. Br J Cancer 87 (4):393-9. DOI:10.1038/sj.bjc.6600467 PMID: 12177775
- ↑ Hochster HS, Hart LL, Ramanathan RK, Childs BH, Hainsworth JD, Cohn AL et al. (2008) Safety and efficacy of oxaliplatin and fluoropyrimidine regimens with or without bevacizumab as first-line treatment of metastatic colorectal cancer: results of the TREE Study. J Clin Oncol 26 (21):3523-9. DOI:10.1200/JCO.2007.15.4138 PMID: 18640933
- ↑ Tournigand C, André T, Achille E, Lledo G, Flesh M, Mery-Mignard D et al. (2004) FOLFIRI followed by FOLFOX6 or the reverse sequence in advanced colorectal cancer: a randomized GERCOR study. J Clin Oncol 22 (2):229-37. DOI:10.1200/JCO.2004.05.113 PMID: 14657227